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M.A., Camb. ; M.D. (State Medicine), B.Sc, Lond. 





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A healthy population is the finest form of national 
wealth, and in an industrialised country its possession 
depends to a large extent upon the completeness of the 
Public Health services and the success they achieve in 
securing a sound environment. In this country great 
efforts are made to promote healthy conditions of living : 
Government Offices administer Public Health measures, 
Local Authorities supervise sanitary conditions, and other 
organisations, public and private, spend vast sums in 
providing medical treatment for the sick. But the value 
of these efforts is seriously lessened by the division of 
administration among a number of uncoordinated authori- 
ties, which overlap in various directions, and yet leave 
large sections of the ground untouched. Social reformers, 
impressed with the confusion and delay resulting from 
this system — or want of system — have long urged the 
formation of a Ministry of Health in order to promote 
efficiency in administration, and it is not necessary at the 
present time to emphasise the importance of any steps 
likely to improve the health of the people. In this book I 
have outlined a scheme for complete reorganisation of the 
Public Health services, both central and local, the most 
important function assigned to a Ministry of Health being 
that of investigating the causes and distribution of disease, 
while actual administration of Public Health measures 


is left to local authorities provided with increased powers. 
To demonstrate the reasons for this scheme it has been 
necessary to take a wide view of the scope of Public 
Health, and to illustrate the way in which efforts to attack 
disease have failed and erroneous views have been dis- 
seminated owing to insufficient investigation of the 
problems involved. For instance, in Chapter II. I have 
examined the question of infection in relation to the 
prevention of disease, with the object of showing that 
fear of infection is unwarrantably exaggerated in the 
public mind, and that segregation of infected persons in 
fever hospitals is useless as a means of preventing or 
eradicating many common infectious diseases. Again, 
in Chapter III. I have shown that there is little scientific 
foundation for the popular view that infant mortality is 
largely a result of adverse pre-natal conditions or maternal 
ignorance and neglect, and have given reasons for believing 
that it is mainly caused by post-natal factors over which 
the mother has little or no control. In succeeding chapters 
I have endeavoured to give a picture of the actual state 
of health among the people in England and Wales at the 
present time, and the extent and distribution of the principal 
diseases, for the purpose of showing the vast scope which 
still remains for the reduction of sickness and mortality. 
The main environmental causes of disease are then brought 
in review, and I have tried to enforce the lesson that 
curative measures yield far less return to the State than 
those which sweep away the conditions causing disease. 

In the last chapter I have urged that the various local 
authorities at present engaged in Public Health adminis- 
tration, or in providing medical services, should be com- 
bined into a single Local Health Authority, responsible 
for protecting the health of the whole community in the 
locality, and providing such medical services as are neces- 


sary. If this proposal were adopted, I would urge that 
care for the health of discharged disabled soldiers, many of 
whom will require medical treatment for prolonged periods, 
should form one of the functions of the authority. This 
suggestion is not considered in the book, because, at the 
time of writing, proposals were indefinite and constantly 
changing. I mention it here in order to deprecate the 
tendency already observable of setting up yet another 
series of institutions and organisations to provide for a 
special class of the community. This remark does not 
apply to the highly useful Committees which are training 
soldiers in handicrafts or assisting them to find work, but 
only to those movements which are concerned with the 
care of their health. 

Throughout the book I have endeavoured to indicate 
the need for far closer investigation by the State of the 
problems presented by disease, and more thorough con- 
sideration of Public Health proposals before they become 
law — ends which can only be achieved by the establishment 
of a Ministry of Health. 

Most of the chapter on the Insurance Act and parts of 
other chapters have appeared in The Nineteenth Century 
and After, and I am indebted to the Editor of that Review 
for kind permission to reproduce them. The chapter on 
Infant Mortality has been published by the Medical Re- 
search Committee, and my thanks are due to the Committee 
for permitting me to include it in the book. My best 
thanks are due to Mr. C. E. West, F.R.C.S., for reading 
the proofs and for many helpful suggestions. 

W. A. B. 

London, February 1917. 




The Sanction of the State to safeguard the National Health . 1 

The antiquity of State protection of Health — Public Health in the 
Middle Ages — The national ' survival value ' of health — The influence 
of disease on the distribution of races — Responsibility for the health of 
native races — Health and social progress — The decline in the birth- 
rate — The demand for the reduction of disease — The great knowledge 
of the means of preventing and curing disease — The failure to apply that 
knowledge — The reasons for the failure : vested interests, complexity 
of administration, and want of knowledge in the legislature. 


Nature and Disease . . . . . . .31 

Evolution against disease : typhus ; smallpox ; enteric fever ; 
scarlet fever ; diphtheria ; tuberculosis ; syphilis — The problems of 
infection — The futility of disinfection — The assurance of the layman — 
The evils of exaggerated claims. 


Infant Mortality and its Problems . . . . .62 

The ' natural ' rate of infant mortality — The avoidable loss of infant 
life in the United Kingdom — Infant mortality in town and country — 
The possible causes of infant mortality : poverty ; defective sanitation ; 
infectious diseases ; artificial feeding ; industrial employment of 
mothers ; lack of attendance at birth — Maternal ignorance — Adverse 
pre-natal conditions — The effect of smoke and dust — The pathological 
causes of infant mortality — Deaths from ' developmental conditions ' 
Still-births — The fall in infant mortality in recent years — Infant 
mortality in Bradford — The need for further research. 




Disease and Defects in Children and Adults . . .114 

Children below the school age — Physical and mental defects in school 
children — Defectiveness in urban and rural children — Employment 
of children out of school hours — Children in special schools and in- 
stitutions — The folly of palliative methods — Sickness in adults — Urban 
and rural sickness rates — Defects in army recruits — The principal 
causes of mortality : tuberculosis ; pneumonia and other respiratory 
diseases; heart-disease; cancer; diarrhoea and enteritis ; syphilis. 


Public Health, Land, and Housing ..... 148 

Man not biologically adapted to life in towns — Rural depopulation — 
The overcrowding of cities and the means of relief — Segregation of 
factories — Bad housing — The difficulties of clearing slum areas — The 
cost of building — ' Summer camps ' — Sleeping out. 


Medical Treatment among the Working Classes . . . 168 

The meaning of ' medical treatment ' — The growth and importance of 
institutional treatment — The insufficiency of institutional treatment — 
Medical treatment by general practitioners — The size of working-class 
practices — ' Lightning ' diagnosis— The absence of expert assistance 
— Diagnosis in general practice — The lack of laboratories for expert 
diagnosis — The futility of treatment in a bad environment— The dis- 
content with the panel system — Medical treatment of school children 
— Mortality in child-bed and its causes — Skilled attendance in child-bed 
— The pathological causes of deaths in child-bed : puerperal fever — 
General practitioner or midwife ? — Attendance in confinement and 
infant mortality — Maternity benefit — The question of a public mater- 
nity service — Medical treatment and Public Health. 


Public Health and the National Insurance Act . . .210 

The Insurance Act a Public Health measure — The German origin of 
the Insurance Act — The principles of administration of the Act — 
Local administration — Medical benefit — The supply of drugs — Sana- 
torium benefit — Sickness benefit — The Insurance Act and insanitary 
conditions — The Insurance Act and the advancement of Public Health 




Public Health and Fraud ...... 265 

Adulteration of food — Unsound food — Conditions under which food 
is prepared — Patent and proprietary foods — Patent and proprietary 
medicines — Unqualified practice. 


The Complexity of Public Health Administration . . 288 

Central administrative authorities — Local administrative authori- 
ties — The evolution of the Public Health services — Administration of 
sanatorium benefit — Administrative authorities and statistics — The 
discouragement of the present system. 


The Need for a Ministry of Public Health . . .311 

The lack of scientific criticism of Public Health measures — The 
need for a Ministry of Public Health — Royal Commissions and Public 
Health research — Administrative Offices and Public Health research 
— The Office of the Registrar-General as the Ministry of Public Health 
— The proposal to form a Ministry by uniting the present administrative 
Departments — The personnel of a Ministry of Health. 


Public Health and Local Administration .... 329 

The responsibility of local authorities — The decline of democratic 
control in Public Health — Local needs and local control — Local ad- 
ministration and the cost of sickness — A single local health authority 
or ' Local Health Council ' — Should the Health Council be the present 
Local Authority or a new body ? — Coordination of the Local Health 
Council and the Local Authority — A suggestion for financial arrange- 
ments — The question of a local medical service — The position of the 
voluntary hospitals — Conclusion. 

INDEX 351 



The antiquity of State protection of Health — Public Health in the Middle 
Ages — The national ' survival value ' of health — The influence of 
disease on the distribution of races — Responsibility for the health of 
native races — Health and social progress — The decline in the birth- 
rate — The demand for the reduction of disease — The great knowledge 
of the means of preventing and curing disease — The failure to apply 
that knowledge — The reasons for the failure : vested interests, com- 
plexity of administration, and want of knowledge in the legislature. 

The Antiquity of State Protection of Health 

Sickness and disease are ancient foes of the human 
race, and men have always acted in concert against 
them. In early stages of society, communities groping 
in ignorance and bewildered by the dangers which sur- 
rounded them, turned to divine power for help. The gods 
of the ancient world, of Babylon, Egypt, Greece, and 
Rome, always included one whose special province was 
the curing of the sick ; and at a later date the aspect of 
Christ as the Healer was prominent in early Christianity. 
Native races to-day entrust to the ' medicine-man,' the 
most potent influence at their command, the duty of 
warding ofr epidemics by incantations. 

Belief in the influence of supernatural power, good or 
evil, upon disease, made the province of healing the sick 
far too important a duty to be left uncontrolled to the 
individual ; and in early societies the function was always 
assumed by the State. In Egypt the practice of medicine 
was restricted to a special class of priests who had studied 
the Sacred Books of Hermes which dealt with the body 



and its diseases. 1 These books were believed to have been 
inspired by Isis herself, and physicians who deviated from 
the laws they laid down did so at their peril. Diodorus 
says : "If, whilst following the rules laid down in the 
" Sacred Book, they do not succeed in saving their patients, 
" they are held free from all guilt ; if, on the other hand, they 
" do anything contrary to those rules, they undergo capital 
" punishment." 2 In Babylon exorcism was practised by 
the priests ; physicians formed an independent class, but 
their efforts were severely controlled by the State, as 
shown by the regulations in the celebrated code of Ham- 
murabi, promulgated about 2280 B.C., which prescribes 
the fees patients are to pay, and ordains heavy punish- 
ments for negligent treatment. 3 In Greece medicine 
reached a high degree of development, and its practice 
was remarkably free from restraint, a condition which led 
Pliny to complain that there was no law to punish the 
ignorance of physicians, who were the only persons who 
might kill a man with impunity. 4 In ancient Rome, on 
the other hand, criminal practitioners might be executed, 
while negligent treatment rendered them liable to pay 

But it was not only in the practice of medicine that the 
State enforced control. Epidemics were believed to be 
due to mysterious agencies or the work of evil spirits, 
nevertheless it was rightly recognised that certain diseases 
are spread by transmission from man to man, and measures 
were taken by the community to prevent their progress, 
by isolating sufferers. Among the Israelites, the priests 
diagnosed leprosy, and for the leper it was laid down that 
" all the days wherein the plague shall be in him he shall 
be denied ; he is unclean : he shall dwell alone ; without 
the camp shall his habitation be." Even conveyance of 

1 H. Oppenheimer, LL.D., " Liability for Malapraxis in Ancient Law," Trans. 
Med. Leg. Society, vol. vii. 2 Bibliotheca Historica, i. 25, 3. 

3 The following examples of these provisions are quoted from Babylonian and 
Assyrian Laws, Contracts and Letters, by C. H. W. Johns : 

"If a surgeon has operated with the bronze lancet on a patrician for a 
serious injury, and has caused his death, or has removed a cataract for a patrician 
and has made him lose his eye, his hand shall be cut off." 

"If a surgeon has treated a serious injury of a plebian's slave with the 
bronze lancet and has caused his death, he shall render slave for slave." 

4 Hist. Nat. xxix. 8. 


disease by clothing was recognised, for if the priest find that 
the garment of the leper is infected, " he shall therefore 
burn that garment, whether warp or woof, in woollen or in 
linen, or any thing of skin, wherein the plague is : for it is 
a fretting leprosy ; it shall be burnt in the fire." x 

In the wonderful system of aqueducts and sewers in 
ancient Rome we may detect appreciation of the import- 
ance of water-supply and drainage in maintaining the 
health of the community. Public baths existed in Greece, 
and at a later date magnificent establishments, often with 
gymnasia attached, were built in Rome, the therapeutic 
value of which was well recognised, as shown by the follow- 
ing epigram quoted by Dr. J. D. Rolleston from the Greek 
Anthology : " The bath is the cause of many blessings. 
It removes the humours, dissolves the thickness of the 
phlegm, empties excess of bile from the bowels, eases 
painful itching, sharpens the eyesight, cleanses the ear- 
passages of the deaf, strengthens the memory, removes 
forgetfulness, clears the mind, makes the tongue more 
active and purifies and lightens the whole body." 2 

Public Health in Later Times 

In mediaeval Europe, the State was continually taking 
measures, superstitious and futile though they were, to 
protect the people from disease. Mainly these were 
directed against the devastating epidemics which swept 
over countries from time to time, divine help being sought 
by prayers, processions, and exhibition of holy relics. 
Jacobus de Voragine, Archbishop of Genoa, writing in the 
thirteenth century, describes the efforts made by Gregory 
the Great as early as a.d. 590 to stay the ravages of a 
fierce outbreak of plague in Rome. He says : " And 
" because the mortality ceased not, he ordained a procession 
" in which he did bear an image of Our Lady, which as is 
" said S. Luke the Evangelist made, which was a good 
" painter, he had carved and painted it after the likeness 
" of the glorious Virgin Mary. And anon the mortality 
" ceased and the air became pure and clear, and about the 

1 Lev. xiii. 2 Trans. Roy. Soc. of Med., 1913. 


' : image was heard a voice of angels." * For hundreds of 
years these processions bearing pictures of the Madonna 
and effigies of saints were ordered by the ecclesiastical 
authorities to traverse the streets in order to stay the 
ravages of plague. In the Litany we still pray to be 
delivered from plague, pestilence, and sudden death. In 
later years, more scientific efforts were made, but it was 
still the State which assumed responsibility. In the plague 
of London the Lord Mayor issued orders for the cleaning 
of the streets, the marking of houses, and the prompt 
burial of the dead, and the King commanded the College of 
Physicians to give advice and prescriptions for treatment. 

The practice of separating lepers from their fellow- 
men was continued during the Middle Ages, sufferers from 
the disease being compelled to live in special houses away 
from the vicinity of towns, and being prohibited from 
entering churches or inns. They were required to wear 
a long grey gown with hood drawn over the face, and 
carry a clapper or bell in order that healthy people might 
know of their approach and shun them. 

The protection of the community against dangerous 
lunatics was another function which was early undertaken 
by the State. At first these unfortunate people were 
treated with great cruelty, confined in gaols, and even 
executed, and it was not until 1547 that the first Bethlehem 
hospital was established for their detention in Bishopsgate. 

Compulsory segregation of the sick was not, however, 
the only means by which the State sought to protect 
Public Health. Although hygiene has only been placed 
on a scientific basis in quite modern times, many of the 
essential causes of ill-health were recognised centuries ago, 
and measures were taken to suppress them. It is no new 
discovery that accumulations of filth, pollution of the air, 
and fouling of water-courses are injurious to health, and 
the archives of the city of London contain records of many 
administrative measures directed against these evils. 2 

1 Quoted by Raymond Crawfurd, M.D., in " Plague Banners," Trans. Roy. Soc. 
of Med., 1913. 

2 A valuable collection of extracts from these archives is contained in Memorials 
of London and London Life in the 13th, 14th, and 15th Centuries, by H. T. Riley. 
These are extensively quoted by Sir John Simon in his English Sanitary Institutions. 


During the thirteenth and fourteenth centuries laws were 
made against permitting pigs to wander in the streets, 
melting tallow in Chepe, flaying horses or slaughtering 
oxen, sheep, or swine in the city, and melting solder in 
Eastchepe " unless the shaft of the furnace was raised." 
Every man was obliged to keep clean the part of the street 
in front of his own house, and the throwing of filth from 
houses into the streets and lanes of the city was forbidden 
under severe penalties. In 1357, Edward III. issued an 
order to the Mayor and Sheriffs prohibiting the throwing 
of filth into the rivers of Thames and Flete, for he " had 
" beheld dung and laystalls and other filth accumulated 
" in divers places in the said city upon the bank of the said 
" river," and had " also perceived the fumes and abominable 
" stenches arising therefrom : from the corruption of which, 
" if tolerated, great peril, as well to the persons dwelling 
" within the said city as to nobles and others passing along 
" the river, will, it is feared, arise unless indeed some fitting 
" remedy be speedily provided for the same." Under 
Henry VIII., Commissioners of Sewers were appointed to 
keep the water-courses in order and prevent them from 
being polluted by refuse. Since these beginnings the State 
has continually increased its control over the water-supply 
in the interests of Public Health, either by itself under- 
taking the service through municipalities, or by enforcing 
laws and regulations when the supply is in the hands of 
private companies. 

Efforts to prevent overcrowding and disease resulting 
therefrom are also of long standing. In 1580, Elizabeth 
issued a proclamation forbidding the erection of new 
buildings in the city or within three miles of its gates, 
but in 1583 the Lords of the Council report that in spite 
of this proclamation buildings had greatly increased, " to 
the danger of pestilence and riot." * An Act of 1593 
recites that " great mischiefs daily grow and increase by 
reason of pestering the houses with divers families harbour- 
ing of inmates, and converting great houses into several 
tenements, and the erecting of new buildings in London 
and Westminster. Under Charles I., the Commissioners 

1 Simon, op. cit. 


of Buildings complain that, " the multitude of newly 
erected tenements in Westminster, the Strand, Covent 
Garden, Holborn, St. Giles, Wapping, RatclifE, Limehouse, 
Southwark, and other parts . . . was a great cause of 
beggars and other loose persons swarming about the city, 
that the greater part of their soil was conveyed with the 
sewers in and about the city, and so fell into the Thames 
to the great annoyance of the inhabitants and of the river ; 
that if any pestilence or mortality should happen, the city 
was so compassed in and straightened with these new 
buildings that it might prove very dangerous to the 

The jerry-builder and slum landlord were early in 
existence, as may be gathered from the following extract 
from a tract of the time of James I.: 1 

The desire of Profitte greatly increaseth Buyldinges, and so 
muche the more, for that this greate Concurse of all sortes of people 
draweinge nere unto the Cittie, everie man seeketh out places, highe- 
wayes, lanes, and coverte corners to buylde upon,yf it be but Sheddes, 
Cottages, and small Tenementes for people to lodge inn. . . . Thes 
sorte of coveteous Buylders exacte great renttes, and daiely doe 
increase them, in so muche that a poore handle craftesman is not able 
by his paynefull laboure to paye the rentte of a smale Tenement 
and feede his ffamilie. Thes Buylders neither regarde the good of 
the Comon-wealthe, the preservacon of the health of the Cittie, the 
maynetenance of honeste Tradesmen, neither doe they regarde of 
what base condicion soever their Tenantes are, or what lewde and 
wycked practizes soever they vse so as their exacted renttes be duely 
payed, the w ch for the moste parte they doe receave either weekely 
or moontheley. 

It is curious to note these efforts made by the State 
hundreds of years ago to prevent overcrowding ; to recall 
that they have been followed by a long succession of 
Housing Acts, Building Acts, and Labourers' Dwellings 
Acts right up to the Town Planning Acts of recent years ; 
and then to reflect upon the deplorable housing and over- 
crowding of large masses of the poorer population to-day. 
Housing is the direction in which Public Health has made 
least progress in spite of much legislation, and this has 
been due partly to the opportunities which the building of 

1 Quoted by Sir Laurence Gomme in The Making of London, 1913. 


houses affords for the creation of vested interests, and 
partly to short-sighted legislation, which, while removing 
evils in one area, has permitted their re-establishment in 

The prevention of adulteration of food and the selling 
of bad food are other directions in which the State early 
concerned itself for the benefit of the community. Dr. 
Wynter Blyth has given an account of these practices and 
the punishment of dishonest vendors in his well-known 
book. 1 Adulteration of wine and bread appears to have 
begun very early. Pliny alludes to frauds practised by 
bakers by adding a soft white earth to bread, and in Athens 
the adulteration of wine led to the appointment of a special 
inspector whose duty it was to detect and stop these 
practices. In Europe, from the eleventh century onwards, 
bakers, brewers, ' pepperers,' and vintners were frequently 
punished for corrupt practices. The sale of bread was 
regulated by Assize as early as 1203. The Assize of 1582 
contains the following : 

If there be any that by false meanes useth to sell meale, for 
the first tyme he shall be grievously punished, the second tyme 
he shall lose his meale, the III tyme he shall foreswere the towne 
and so likewyse the bakers that ofTende. Also bouchers that sell 
mesell porke or mozen flesche : for the first tyme they shall be 
grievously amerced, for the second tyme so offendinge they shall 
have the judgement of the pillory, for the third tyme they shall be 
comytted to pryson until ransomed, and the fourth tyme they shall 
foreswere the towne ; and thus ought other transgressors to be 
punished, as cooks forestalled, regrators of the markets when the 
cookes serve, roste, bake, or any otherwyse dresse, fysche or flesche 
unwholesome for man's body. 

Many other instances are given by Dr. Blyth of severe 
punishments for adulteration of food. An Ordonnance of 
Paris of 1396 forbade the colouring of butter with ' saucy 
flowers,' other flowers, herbs, or drugs. In 1491 three 
bakers convicted of selling bread ' too small ' were stripped 
and beaten with rods through the streets of Paris. At 
Biebrich in Germany, in 1482, a falsifier of wines was 
condemned to drink six quarts of his own wine. He died 
from the effects. 

1 Foods : their Composition and Analysis. 


The nineteenth century witnessed a great development 
of State activity on behalf of Public Health in all civilised 
countries. In the British Isles, general sanitation, housing, 
water-supply, food, milk, infectious diseases, insanity, 
training of midwives, medical qualifications, Poor Law 
infirmaries, protection of infant life and maternity, and 
provision of medical treatment have all been the subject 
of Acts of Parliament, many of which have been amended 
and enlarged time after time. Principles of hygiene are 
enforced in the home, the school, the mine, and the factory. 
The early and inhuman methods of segregating infected 
persons have long disappeared, and have been succeeded 
by a system of compulsory notification of disease, com- 
bined with provision for treatment in fever hospitals, 
which is accepted voluntarily in the vast majority of 

If we look at the legislation of the last half -century > it 
is safe to say that Public Health measures in one form or 
another have occupied a larger share of Parliamentary 
time than either trade, finance, education, or even national 
defence, yet alone of these activities does it not possess a 
special Government Department. In the Middle Ages, 
under the influence of monasticism, the body was regarded 
as the enemy of the soul, and the efforts of States under the 
guidance of an all-powerful Church were directed towards 
securing salvation in an after-life. No punishments were 
too great for infringement of ordinances which might 
imperil that salvation, and men have been hanged for 
eating meat on a Friday and for blasphemy. So late as 
1754 the proposal to register all births and deaths in this 
country was defeated in Parliament, owing to popular opposi- 
tion on the ground that it would involve committing the sin 
of David. 1 In a more enlightened age, care for the bodily 
health, as far as the State is concerned, has replaced the 
mediaeval care for the soul, and the Churches also have 
extended their mission to the alleviation of disease in this 
world. In the words of Bishop Byle, Dean of Westminster : 
"It is no longer sin which seems to be regarded as the 
foe, but physical disease, suffering, and death. The war- 

1 Gentleman's Magazine, 1754. 


fare which excites public sympathy is the warfare against 
' bacterial rulers of darkness,' against epidemics, against 
fevers, against cancer." * 

The Prominence of Preventive Measures 

Before examining the profound meaning of the concern 
which States have always displayed for the health of 
their members, we may note one feature which has been 
prominent throughout, and that is the large share in the 
national efforts occupied by preventive measures. The 
importance early attached to water-supply, removal of 
refuse, and overcrowding illustrate this point. The ruth- 
less sacrifice of the individual for the protection of the 
community is exemplified by the laws made against the 
leper. The measures taken against epidemics, such as 
the carrying of holy relics or the lighting of fires in the 
streets, had for their object the averting of the terror from 
those who were untouched, for the sick were often allowed 
to die in solitude and neglect. Compulsory vaccination, 
notification of disease, and all our recent sanitary efforts 
are directed towards the prevention of sickness. 

Curative measures, on the other hand, such as provision 
of refuges for the sick and of medical treatment, have not 
formed a conspicuous feature of State activity until quite 
recent years. Everywhere the earliest institutions for 
the sick were the outcome of individual benevolence or 
were established by religious orders ; and the great hospital 
system in this country, which had its origin in the monastic 
institutions, has been developed almost entirely by private 
energy and munificence. Some provision was made for 
the care of the sick poor in the sixteenth century, but 
except for an extended use of the fever hospitals, it was 
not until the passing of the Insurance Act that any attempt 
was made on a large scale to provide medical treatment 
through the State for persons not belonging to the indigent 
class. The State in the past has indeed been little moved 
by motives of sympathy ; its ordinances have been framed 
by the sound for the protection of the sound, and the 

1 Sermon preached at Westminster Abbey before the members of the Seven- 
teenth International Congress of Medicine, London, 1913. 


sick have been left to fend for themselves, or seek help 
from the more kindly of their fellow-creatures. Even 
when provision has been made by the State, it was quite 
clearly the outcome of desire to protect others rather than 
of solicitude for the sick. The cruelties which weie in- 
flicted on lunatics show that they were not confined for 
their own benefit, but mainly for the protection of the 
public ; and the earlier Poor Laws were directed quite as 
much towards the repression of mendicity and petty 
crime as towards providing for the infirm poor. Harsh 
though this attitude may appear, it has probably been 
based upon a sound national instinct, for the sick person 
was often of no further use to the community, and the 
State was concerned only in protecting the community 
with little reck for the sufferings of the individual who 
fell by the wayside. 

The National ' Survival Value ' op Health 

National concera for the communal health was probably, 
in the first instance, a development of the ' herd-instinct ' 
which leads gregarious organisms to unite for their common 
protection. The survival value of this instinct is seen 
in its simplest form in savage tribes, among whom it is 
obvious that that tribe which can place the largest number 
of able-bodied warriors in the field has the greatest chance 
of overcoming its enemies in a conflict where defeat may 
mean annihilation. The principle equally applies, though 
on a much larger scale, to European warfare to-day, when 
belligerent nations strive to arm as large a proportion as 
possible of their adult male populations. The number of 
men available bears a very direct relation to the average 
state of health of the nation, and we know that in this 
country it has been found necessary to exempt a sub- 
stantial proportion of men from military service either by 
reason of their defects and ailments, or from their failure 
to attain a standard of growth which, measured by well- 
developed individuals, must be looked upon as lamentably 

In the industrial competition between peoples, national 


health also plays an important though perhaps less con- 
spicuous part. We have an example in the Insurance 
Act of the way in which the State looks upon health from 
the utilitarian standpoint. That Act does not purport to 
cure or prevent disease in the community, but only in the 
working part from whom some return can be expected ; 
furthermore, it definitely lays down that i incapacity for 
work,' and not ill-health is the criterion for receiving 
benefit, and that assistance ceases when capacity for 
work is regained, though this by no means necessarily 
connotes return to full health. 

With the growth of knowledge and civilisation, the 
primitive instinct of the savage to protect the national 
health is reinforced by recognition of the influence disease 
has in bringing about poverty, crime, inebriety, and other 
evils. It is seen that when the bread-winner is laid low 
by sickness, not only he but his entire family may become 
a burden on the State ; the pathological element in much 
crime is recognised ; and inebriety is more and more traced 
to the degeneracy which results from a combination of 
vicious influences. The Poor Laws contain an effort to 
meet the destitution caused by disease, and the establish- 
ment of criminal lunatic asylums is a recognition of the 
fact that disease may be responsible for crime. Still later 
in social progress it is recognised that in providing for the 
health of the nation the State must look beyond the 
existing generation. It is learnt that steps taken now 
will act and react upon posterity for long periods, and that 
the best way to provide sound health in the future is to 
secure it in the infants and children of to-day. Though 
long appreciated by students, the lateness of the State to 
receive and act upon this conception is illustrated by the 
fact that, in the history of Public Health efforts, measures 
to protect the lives and welfare of infants were the last to 
find a place. 

Thus in numerous directions sound health is of the 
greatest importance to a people, and may even determine 
its very existence. And since the number of those who 
cannot contribute to the general advancement of the 
community, who, whether from disease or stunted growth, 


are unfit for military service or drop out of the industrial 
army, or become a burden on the healthy, depends more 
upon the environment than upon any other factor, the 
responsibility for maintaining a healthy environment and 
thereby reducing national waste to a minimum is one 
which must be accepted by the whole community. 

Health and Empire 

So far we have been considering the survival value of 
health in a people limited to one country, but the question 
has aspects of still greater importance to a nation 
with colonies and dependencies all over the world. The 
influence of disease in fixing or modifying geographical 
boundaries has been considerable ; and the present dis- 
tribution of peoples on the globe has been largely deter- 
mined by the prevalence of different diseases in different 
areas. The white man has failed to colonise many of the 
fairest and most fertile regions of the earth owing to the 
deadly effect upon him of malaria, yellow fever, and other 
tropical diseases ; and the negro when associated with 
white communities suffers severely from tuberculosis. 
But modern science has discovered the causes of many of 
the diseases which have hitherto stood in the white man's 
path, and has shown that they can be successfully attacked, 
thus foreshadowing an entirely new era in colonisation. 
Countries hitherto almost uninhabitable by Europeans 
are now being rendered healthy and fit for occupation. 
Already one striking result of the new knowledge has been 
seen. De Lesseps and his successors failed to construct 
the Panama Canal mainly because of the frightful mortality 
from malaria and yellow fever among the labourers. But 
the researches of Laveran, Koch, Manson, Koss, and 
others on malaria, and of Reed, Carroll, Lazear, and 
Agramonte on yellow fever, have shown that the parasites 
of these diseases are conveyed by mosquitoes, and that by 
taking precautions against the bites of these insects, 
draining the pools and marshes which are their breeding 
places, and preventing the development of the larvae by 
covering the surface of stagnant water with petroleum, 


both diseases can be practically eliminated. By adopting 
such measures Colonel Gorgas, acting under the American 
Government, was able to bring to a successful conclusion 
one of the greatest engineering works of modern times. 
Similar efforts in other countries have been equally success- 
ful in reducing the incidence of these diseases, and there 
is good reason to believe that science has now provided a 
weapon which will enable mankind eventually to rid itself 
of one of its most deadly scourges. 

It is obvious that work of this sort not only ought, but 
can only efficiently be carried out by the State. It is true 
that the foundation work, the patient scientific research, can 
be and usually has been conducted by individual effort 
and initiative ; but without State assistance these efforts 
are necessarily limited, and until quite recent years this 
country has not been conspicuous for the help it has 
rendered to scientific research, or for the rewards it has 
bestowed upon those from whose labours it has derived 
so great benefit. But the application of this knowledge 
to a community demands funds, organisation, and control 
which can only be provided by the State, whether it be 
to reduce malaria or plague in India, blackwater fever in 
West Africa, beri-beri in the Malay Archipelago, sleeping 
sickness in Uganda, or yellow fever in South America. 
To a very considerable extent indeed this has been realised 
and acted upon, and colonising Powers are now setting 
up laboratories at home for the study of tropical diseases, 
and in their colonies are opening hospitals, establishing 
State medical services, promoting sanitation, and spread- 
ing knowledge of hygiene by means of leaflets, lectures, 
and teaching in schools. Study of reports such as those 
issued by the Advisory Committee for the Tropical Diseases 
Research Fund reveals a most gratifying picture of the 
energy which is being displayed in combating disease in 
the remoter parts of the world. It is a remarkable fact 
that it has been found possible in many colonies and 
dependencies to take steps, such as the establishment of 
State medical services, which vested interests have 
rendered impracticable in mother-countries. 

Still, there is another side to this picture. Our achieve- 


ments should be measured not by what we are doing, but 
by what we might do having regard to our knowledge, 
and we learn from the words of Sir Ronald Ross in the 
Huxley Lecture for 1914, that we have still far from made 
full use of that knowledge. 1 After describing the extent 
to which diseases are carried by insects and other organisms, 
he said : " We now have a great sanitary ideal put before 
us — so to manage our habitations, villages, towns, and 
cities that the vermin in them shall be reduced to the 
lowest possible figure. ... It demands only intelligence, 
energy, and organisation on the part of administrators. 
Unfortunately these qualities are not always forthcoming, 
and administration often lags years behind the dictates 
of science. Although fifteen years have elapsed since 
many of the facts which I have described were discovered, 
I think that I may say, after constant study of the subject 
and with all due consideration, that mankind has hitherto 
not effected more than about one-tenth of the improve- 
ment of health which it might have effected already if it 
had put its heart into the business. When I had com- 
pleted my work in 1899, I had fondly dreamed that a few 
years would see the almost complete banishment of 
malaria from the principal towns and cities in the tropics 
— that those benign climates and those beautiful scenes 
would be almost rid at once of a scourge which had blighted 
them from time immemorial. In this I have been dis- 
appointed. True, much has been done in certain places, 
as in Panama, Ismailia, Italy, West Africa, and parts of 
India and the Malay States, and in some other spots ; but 
much more might have been done had we remained fully 
alive to our opportunities — and our duties. It is not the 
fault of science that we do not fully utilise the gifts which 
she gives to us." 

Responsibility for the Health of Native Races 

Apart altogether from colonial expansion or commercial 

development, a great colonising Power like Britain is 

under a strong moral obligation to protect the health of 

subject races over which she rules, races of different colour, 

1 Recent Advances in Science and their bearing on Medicine and Surgery. 


diverse religions, and varied social customs. In regard to 
India the obligation is all the greater since her native 
troops have been called upon to fight in European war- 
fare. In the main this obligation has been recognised and 
much has been done to discharge it, but the terrible 
ravages of disease in India and the Dependencies shows 
that there is still vast scope for action. In India, during 
the last eighteen years, more than eight and a quarter 
millions of persons have died from plague, and seven 
millions from cholera. 1 Deaths from malaria have been 
officially estimated at 1,200,000 a year in ordinary years, 2 
and since the case mortality is small the total number of 
persons infected must be enormous. Tuberculosis is 
considered by Dr. C. Muthu to cause an annual mortality 
of over a million, and the rate has been steadily rising 
since 1901. 3 In Uganda, sleeping sickness is estimated to 
have caused 200,000 deaths between 1897 and 1906. 
This country also provides an illustration of the tragic 
consequences which may follow the abandonment of 
native customs under the influence of European civilisation. 
Before the British occupation of Uganda polygamy was 
practised by the natives, and in consequence few women 
were unprovided for, and there was little or no prostitution. 
The introduction of Christianity led to the abandonment 
of polygamy, removal of restrictions on the liberty of 
women, and abolition of punishments for immoral offences, 
with the result that a prostitute class came into existence, 
and a devastating outbreak of syphilis occurred. 4 Colonel 

1 Report by Dr. R. W. Johnstone to the Local Government Board on the 
Progress and Diffusion of Plague, Cholera, and Yellow Fever throughout the World, 
1913. 2 Ross, op. cit. 

3 " Tuberculosis in India," Practitioner, June 1915. 

4 The Rev. J. Roscoe, C.M.S., Chief of the Theological College at Kampala, 
who has spent twenty-five years in Uganda, says : "Among the Baganda up to about 
twelve years ago a custom prevailed of keeping the women belonging to the tribe 
under strict confinement and surveillance . . . hence immorality and promiscuous 
intercourse did not exist. At approximately the time of the outbreak of syphilis 
the chiefs of the Baganda tribe, the majority of whom had become Christians, 
decided to remove these restrictions as being contrary to Christian teaching and 
set the women free. This was done, and from that time the women were released, 
henceforth to roam where and whither they willed, and do as they liked. The result 
of the removal of these restrictions was exactly what one would have expected, i.e. 
promiscuous sexual intercourse and immorality. I consider the above to have 
been the main cause of the outbreak of syphilis among the tribes of the Protector- 
ate." — Quoted by Col. Lambkin in A System of Syphilis, edited by D'Arcy Power, 
F.R.C.S., and J. Keogh Murphy, F.R.C.S., vol. ii., 1908. 


Lambkin, who was appointed by the Government to in- 
vestigate the conditions, estimated that more than half 
the population of the Protectorate was infected, and that 
in some parts of the country the incidence of the disease 
was as high as 90 per cent, and was responsible for more 
than half the total infant deaths. He concludes by saying 
that : "In fact, as things stand at present owing to the 
presence of syphilis, the entire population stands a good 
chance of being exterminated in a very few years or left 
a degenerate race fit for nothing." x 

Sir Harry Johnstone has said of the Baganda tribe : 
" In my opinion there is no race like them among the negro 
" tribes of Africa. They are the Japanese of the Dark 
" Continent, the most naturally civilised, charming, kindly, 
"tactful, and courteous of the black people." Acting 
under the best of motives, we have forced alien ideas 
upon these people, and have interfered with their social 
customs without taking due precautions for their safety ; 
and the result has been that we have unwittingly caused 
a hideous tragedy in the native villages of a country we 
have rechristened a " Protectorate." 

Health and Social Progress 

We have considered the part which is played by health 
in determining the military strength of a people, its 
relation to other countries, and its colonising power, and 
we must now note the not less important value of health 
in internal affairs. The immense effect of sickness in 
producing poverty is so well known, and has been so ably 
investigated by many writers, that there is no need to 
dwell further upon it here. On the other hand, the 
influence of poverty in producing sickness has perhaps 
been exaggerated. We shall see that it is quite possible 
to be extremely poor and extremely healthy, and that 
some of the healthiest classes in these Islands are among 
the most poverty-stricken. The human species needs but 
little to keep it in health — simple food, homely clothing. 
and the rudest of shelters will suffice — though this is not 

1 Op. cit. 


to say comfort and happiness ; yet even these, health alone 
will go a long way towards providing. Poverty acts as 
a cause of disease mainly by compelling people to live in 
an unnatural and unhealthy environment, and so long as 
they remain in that environment neither Poor Law doles 
nor sickness benefit will appreciably improve their health. 

Much crime and vice has now also been shown to be 
due to a state of degeneracy, one of the main factors in the 
production of which is sickness. Dr. Goring 1 has shown 
that there is no such thing as a criminal type, and we have 
almost got rid of the notion that a tendency to commit 
crime is inherited, save in a small proportion of persons 
born with a definite pathological disorder such as feeble- 
mindedness or epilepsy, a belief which was largely the 
result of flagrant misunderstanding of various social in- 
vestigations, as, for example, that made by R. L. Dugdale 
into the history of the so-called 'Jukes' family. 2 A 
widespread improvement in health would lessen crime, 
inebriety, and other vices, and relieve the State of part 
of its burden in maintaining prisons, police forces, and 
homes for inebriates. 

In other directions sickness leads to loss of labour and 
wages, added expense in production, diminished efficiency, 
and waste of educational opportunity, for there are always 
a considerable proportion of children away from school by 
reason of ill-health. 

We shall see in succeeding chapters that the largest 
factor iD the causation of disease and mortality is a defec- 
tive environment, particularly that of an overcrowded 
town, and that a high proportion of sickness — not exactly 
measurable, but probably not less than a third of the 

1 The English Convict : a Statistical Study. 

2 Professor Giddings, in his introduction to the fourth edition of The Jukes, 
a Study in Crime, Pauperism, Disease and Heredity, says : " An impression quite 
generally prevails that ' the Jukes ' is a thorough-going demonstration of ' heredit- 
ary criminality,' ' hereditary pauperism,' ' hereditary degeneracy ' and so on. It 
is nothing of the kind, and its author never made such claim for it. Far from 
believing that heredity is fatal, Mr. Dugdale was profoundly convinced that environ- 
ment can be relied on to modify and ultimately to eradicate even such deep-rooted 
and widespread growths of vice and crime as the ' Jukes ' group exemplified." 
The book shows quite clearly that those members of the family who lived under 
vicious influences became criminals, paupers, and prostitutes, while those who had 
opportunities of getting into a better environment became steady and industrious 
members of the community, yet curiously enough it has been the illustration most 
quoted by those who believe in the all-powerful influence of heredity. 



total — could be avoided by securing a healthy environ- 
ment. The economy to the State which would result from 
appreciably lessening sickness and disease would be very 
large. At present we spend immense sums on sanatoria, 
Poor Law infirmaries, public hospitals, medical services, 
and sickness benefit, and to these must be added the 
great volume of charitable donations which maintain 
the voluntary hospitals, and private expenditure on medi- 
cal treatment ; yet all this outlay, amounting to many 
millions, does nothing to alter the environmental conditions 
which are mainly responsible for disease, and very little to 
prevent the spread of disease. A keener sense of sympathy 
with suffering is probably the reason why so much greater 
attention is now given to curative measures, but the earlier 
policy of directing efforts mainly towards the prevention 
of disease was the sounder, and in the long run is of the 
greater benefit to the community. 

The Decline in the Birth-Rate 

There is yet another reason for urging national care for 
national health, and that is the heavy and continuous fall 
which has occurred in the birth-rate during the last thirty 
or forty years. The effects which this fall will ultimately 
have on the population are far from being generally 
appreciated. Simultaneously with the decline in the birth- 
rate there has been a fall in the death-rate, though not to 
so great an extent ; and it has been generally assumed that 
the low death-rate would continue and that, provided the 
birth-rate did not fall below a certain point, there would 
always be a comfortable margin between the two rates, 
which would secure a reasonable annual increase of popu- 
lation. But the question is not merely a simple one of 
subtraction of death-rate from birth-rate. The ultimate 
effect of a long-continued fall in the birth-rate is to raise 
the average age of the population ; and as this rises, the 
death-rate increases altogether apart from any environ- 
mental conditions influencing disease. We see the effects 
of this process in the relatively high death-rates in France 
and Ireland, in the one case due to restriction of births, 


and in the other to long-continued emigration of the 
younger people. Yet both these countries offer healthier 
conditions of life than England, and their death-rates 
when made truly comparable by standardisation are lower 
than that of England. Thus sooner or later it seems 
inevitable that we shall have a rise in the crude death- 
rate in this country, and it is probable that the turning- 
point has already been reached and passed, for the death- 
rate after falling steadily for many years has been rising 
since 1912. 

The increase in the average age is not limited to the 
death-rate in its effect. Eventually it begins to reduce 
the proportion of women of reproductive age in the popula- 
tion, which combines with deliberate restriction in still 
further lowering the birth-rate. Hence with a death-rate 
rising, a birth-rate tending to fall at an accelerated rate, 
and the probability of extensive emigration after the War, 
we are within measurable distance of a stationary if not 
a declining population in this country. 

The effect of the fall in the birth-rate is equivalent to 
a loss of life immensely greater than has ever been pro- 
duced by the most devastating epidemic, but since it is 
not accompanied by the open horrors of an epidemic, the 
matter is one which excites very little concern. The 
causes of the decline in the birth-rate are well known, but 
it is not easy to see what steps could be taken by the State 
to arrest the process, and indeed it is very doubtful whether 
any action by the State would be effective. There is one 
school of opinion which considers that the fall in the birth- 
rate has been highly beneficial to the nation, and actively 
encourages its furtherance; but whatever views may be 
held on this point, there can be no two opinions but that, 
in view of the fall, the State should strive to make the 
very best of the population which does come into existence. 
No Government is in a strong position to go to mothers 
and urge them to have more children so long as the infant 
mortality rate remains at least twice as high as it need 
be, and many thousands of young lives are sacrificed 
annually to preventable causes. 


The Demand for Reduction of Disease 

No big step in social progress is possible without the 
active sympathy of large masses of the community, and 
in this respect the movement for improving the national 
health has the greatest support. Probably at no time have 
men had so strong a sense of responsibility for others as 
at present ; and the keen desire to relieve human misery 
resulting from disease shows itself in the large army of 
social workers who as members of Care Committees, Boards 
of Guardians, Social Service Leagues, Societies for the 
abolition of tuberculosis, syphilis, and other diseases, 
hospital committees, infant clinics, medical aid institu- 
tions, and other organisations, are devoting themselves 
to helping their less fortunate fellow-creatures. Much of 
this work is wasted owing to lack of coordination between 
the different bodies, and sometimes to excess of zeal with- 
out corresponding knowledge ; but the motive for these 
efforts indicates an appreciation of national needs which 
is the best augury for progress. It is certain that the 
vast bulk of the people in this country do not want the 
state of wretchedness at present existing among large 
sections of the poor in big cities to continue. Demand 
increases for vigorous attack on the evils which destroy 
health ; and discontent is widely expressed with the half- 
hearted measures adopted by Parliament, the unrealised 
promises of Ministers, and the incompetence of official 
administrators. Mr. Galsworthy has given voice to this 
widely-felt sentiment in the following words : "I am 
moved to speak out what I and, I am sure, many others 
are feeling. We are a so-called civilised country ; we have 
a so-called Christian religion ; we profess humanity. . . . 
And yet we sit and suffer such barbarities and mean 
cruelties to go on amongst us as must dry the heart of 
God. I cite a few only of the abhorrent things done daily, 
daily left undone ; done and left undone without shadow 
of doubt against the conscience and general will of the 
community — sweating of women workers ; insufficient 
feeding of children ; employment of boys on work that 
to all intents ruins their chances in after life, as mean a 


thing as can well be done ; foul housing of those who have 
as much right as you and I to the first decencies of life. . . . 
And I say it is rotten that for mere want of Parliamentary 
interest and time we cannot have manifest and stinking 
sores such as these treated and banished once for all from 
the nation's body. . . . Parliament is an august assembly 
of which I wish to speak with all respect. But it works 
without sense of proportion or sense of humour. Over 
and over again it turns things already talked into their 
graves ; over and over again listens to the same partisan 
bickerings, to arguments which everybody knows by 
heart, to rolling periods which advance nothing but those 
who utter them. And all the time the fires of live misery 
that could, most of them so easily, be put out, are raging, 
and the reek thereof is going up." 1 

Sympathy for manifest evils, and self - sacrifice for 
others have no limit when the emotions are directly 
stimulated. In a mining disaster, volunteers are always 
ready to face almost certain death in order to rescue their 
comrades. A few years ago a man was overcome by 
deadly gases in a sewer. A fellow-labourer fully cognizant 
of the danger at once descended to help him, but fell from 
the ladder when halfway down ; another descended and 
yet another. When eventually brought up, three of the 
four were dead. Such acts of heroism, unexcelled by 
anything done on the battlefield, serve to show the strength 
of the social spirit among us. The difficulty is to arouse 
this spirit against evils of which the knowledge must be 
conveyed through the intellect and not by the immediate 
stimulus of the emotions. Many who would spare no 
effort to help a person injured in the streets before their 
eyes, will read quite unmoved a statement that, " the 
hospital provision in England is seriously inadequate." 
Only those who know by experience what these words 
mean — -the sickening delays, the anxiety of those waiting 
for surgical treatment, the needless suffering, and even 
loss of life — appreciate their tragic significance. The daily 
record of horrors from the battlefield leads all classes to 
contribute from their wealth or services to the assistance 

1 Times, February^28, 1914. 


of wounded soldiers, but we do not hear of great houses 
being placed at the disposal of men injured in a colliery 
disaster, or of aristocratic ladies ministering to sick cotton 
spinners of Lancashire, yet both these classes risk life 
and health in doing work which is essential for national 
welfare. The sympathy for them certainly exists, but the 
stimulus needed to evoke it is lacking. This aspect of 
the human mind has been finely expressed by Mrs. E. B. 
Browning in Aurora Leigh : 

A red-haired child 
Sick in a fever, if you touch him once. 
Though but so little as with a finger-tip, 
Will set you weeping ; but a million sick . . . 
You could as soon weep for the rule of three, 
Or compound fractions. 

Knowledge of the Means of preventing and 
curing Disease 

Desire to prevent or cure disease would be of little 
effect without knowledge of the means by which these ends 
can be achieved, and of this knowledge we now possess a 
large store. Medicine has still much to learn ; the problem 
of cancer remains unsolved, and the cure for many diseases 
has yet to be discovered, nevertheless the advances made 
during the last thirty or forty years have been unprece- 
dented. Surgery, in particular, has saved many thousands 
of lives and done much to repair the crippling effects 
of disease ; serum therapy and kindred methods have 
proved their curative value in diphtheria and their preven- 
tive effects against tetanus and typhoid under the severe 
test of war ; bacteriology has furnished new means of 
determining the presence of grave diseases ; and X-rays, 
light rays, and radium have provided potent aids to 
diagnosis and treatment. Not less great, too, have been 
advances in knowledge of preventive medicine. We are 
still uncertain of the ways in which many diseases are 
transmitted, and the whole subject of infection demands 
further study, but statistics now enable us accurately to 
recognise unhealthy occupations and locate disease-propa- 
gating areas. The refinements of chemistry and physics 


have provided new methods of examining water, analysing 
foods, testing the condition of the air, and disposing of 
refuse and sewage. 

The Failure to apply Knowledge 

For securing sound Public Health, then, two important 
conditions are fulfilled : there is first the widespread desire 
among all classes to reduce sickness and disease, and there 
is the knowledge furnished by science, which should enable 
that end largely to be attained ; but when, bearing in mind 
these facts, we survey the actual condition of large masses 
of the English people to-day, the relatively small extent 
to which that knowledge is utilised for the public welfare 
is little short of amazing. We know that bad housing 
and, particularly, overcrowding are fruitful causes of 
disease, but all our large cities exhibit huge slum areas, 
dirty, dismal, and unhealthy, where the infant mortality 
rate reaches a height which would disgrace a savage people, 
and where the efforts of local authorities, hampered by 
vested interests, succeed only in clearing tiny areas often 
after years of negotiation. We know that pollution of 
the air is a serious evil to health, yet our laws make only 
the discharge of black smoke from a factory chimney an 
offence, and brown or yellow smoke may be emitted in 
any volume with impunity ; our methods of collecting 
dust are primitive, and we allow household refuse to be 
tipped into open carts, and dust-carts to pass through the 
streets at all times of day, filling the air with a cloud of 
filth at every gust of wind. We know that pure milk 
should be one of the staple foods of all young children, 
yet the reports of the Local Government Board show that 
something like 10 per cent of the samples analysed are 
adulterated, while 10 per cent contain the bacilli of tuber- 
culosis. We know the harmfulness of eating adulterated 
food, yet adulteration was probably never more widespread 
than it is to-day, many of our commonest foods being 
habitually sophisticated, while the laws intended to prevent 
this practice are ineffective, and the penalties imposed 
upon offenders are usually quite inadequate. We deplore 


the ignorance of mothers and we try to encourage breast- 
feeding, and at the same time we allow vendors of patent 
foods for infants to placard every hoarding with lying 
advertisements of their wares. We declaim against in- 
temperance, while we permit ' medicated ' wines to be 
sold widely to the ignorant under the pretence that they 
are beneficial to health. Our general water-supply and 
the drainage systems in most towns are in fact the only 
directions in which we have attained the standard of 
excellence demanded by modern knowledge. The pro- 
vision for curative treatment is equally out of accord with 
what we know to be required. In spite of the good work 
done by the voluntary hospitals and many infirmaries, 
the numbers of beds available in institutions for the sick 
is insufficient to meet the needs of the community. The 
medical inspection of school children only covers a part of 
the field, and the arrangements for medical treatment of 
the children are still less complete. The more scientific 
methods for diagnosing disease, and the services of 
specialists in various directions are beyond the reach of 
large masses of the people ; and the medical treatment 
provided through the Poor Law or Insurance systems is 
thoroughly unsatisfactory in many districts. 

If the application of our knowledge bore a reasonable 
relation to its amount, we should have a vigorous and 
healthy population, whereas the true state of affairs is 
revealed by the returns of infant deaths, the deplorable 
condition of school children in towns, and the high pro- 
portion of would-be recruits who are rejected from military 
service. We are apt to get an exaggerated idea of the 
health of the people and of the effects of administrative 
measures which have been taken in the past, partly because 
nearly all our blue books and official reports on Public 
Health, issued by those responsible for the establishment 
or working of these measures, are distinctly partisan and 
often very unscientific in their statements and claims ; * 

1 A well-known writer in The New Statesman, criticising the Second Annual 
Report of the Insurance Commissioners, says : " In short the Report is so success- 
ful in failing to afford any picture of how the Act is working, that we are driven to 
the inference that it has been no less successfully ' edited ' with the intention of 
revealing no significant facts or crucial points that have not already been published 
in Ministers' answers to questions or otherwise." The Annual Reports of the 


and partly because of the inveterate habit of politicians 
and reformers when speaking on Public Health to draw- 
glowing comparisons with conditions in past times. We 
are continually reminded of the fall in the death-rate, 
the disappearance of typhus, and the decline in tuberculosis, 
for all of which credit is given without any hesitation to 
administrative measures, though, as we shall see in the 
next chapter, often with little foundation. But the past 
is not the right standard of measurement ; comparison 
should be between what we do and what we might do if 
we made full use of our vast stores of knowledge. We 
have no more right to take credit because things are 
better than they were fifty years ago, than we should 
have if we armed our soldiers with muskets, and pointed 
with pride to the fact that they were a great improvement 
on bows and arrows. 

The Reasons for the Failure 

To trace the reasons for the failure to make the best 
use of medical and Public Health knowledge is the main 
object of this book. The task is not easy, for the factors 
operating are too diverse and yet too interwoven in their 
effects to permit of a simple scheme in setting them forth ; 
moreover, it will be necessary as we go along to establish 
scientifically, as far as possible, various statements briefly 
summarised in the preceding pages, many of which will 
have appeared too sweeping at first sight. 

Broadly speaking, the reasons why results in Public 
Health have been so incommensurate with efforts are 
three in number : viz. the opposition from vested interests ; 
the complexity of Public Health administration ; and the 
want of expert knowledge in those who frame the laws 
and those who administer them. Vested interests offer 
difficulty to Public Health progress in many directions. 
Reference is not made here to the unscrupulous member 
of a Local Authority or Board of Guardians who uses his 
position to further his own private ends, or to the dis- 

Registrar-General and the scientific monographs on Public Health subjects issued 
from time to time by the Local Government Board must be exempted from the 
general criticism made in the text. 


honest trader who adulterates the food he sells, but to the 
much larger legitimate interests which the sense of justice 
of the community, now or in past times, has decreed shall 
not be disturbed without due compensation. There is 
the landlord or house-owner, who is entitled to the highest 
rent he can get, although overcrowding and bad housing 
result ; there is the Borough Councillor, himself often a 
tradesman, who, without any personal end, naturally 
inclines towards the protection of trade interests ; there 
is the factory-owner, in whom it would be sheer altruism 
to do more for the health of his employees than is required 
by the law ; and there is the doctor, who having built up 
a practice by his own efforts, fights legitimately against 
proposals to establish medical services which appear to 
threaten his interests. These are well-recognised instances, 
but in many less obvious ways vested interests, perhaps 
quite low down in the social scale, make their appearance 
and impede Public Health progress. Even the dustmen 
have successfully resisted innovations in the system of 
collecting dust which seemed likely to reduce their per- 
quisites. 1 The effects of vested interests upon Public 
Health will be described in later chapters, but the methods 
of overcoming these interests, with due observation of the 
principles of justice, are economic questions which do not 
concern this book. 

The complexity of Public Health administration is a 
result of the piecemeal way in which the Public Health 
system has grown up in this country. The health of the 
people and causes of disease have never been dealt with 
as a whole, but the legislature has at different times made 
provision for different groups of people and for treating 
different diseases ; and as each new measure has been 
adopted, the duty of carrying it out has, in the absence of 
one central administrative authority, been thrust upon 
some Department perhaps established originally for a 
totally different purpose, or has been assigned to a new 

1 The authorities of a certain town recently proposed to establish a system by 
which a cart, especially built to hold a number of bins, would deposit an empty 
one at each house and take away the filled receptacle without its being opened. 
The dustmen, however, raised strong opposition, and it was found that they claimed 
as a perquisite the right to pick over refuse and take bottles, tins, etc. A strike 
was threatened, and the project was in consequence abandoned. 


authority created ad hoc. The consequence is, that the 
central administration of Public Health is divided up 
among eight or ten different Departments, uncoordinated 
to an extent which is known only to those who have had 
actual experience in a Government Office. Some of these 
Departments do not know what the others are doing or 
have done ; some are working in contrary directions ; and 
sometimes they produce reports on the same matter 
leading to different conclusions, or sets of statistics hope- 
lessly at variance with each other, — all factors which com- 
bine to produce friction, delay, and inefficiency. Locally, the 
confusion is repeated owing to the division of Public Health 
administration among Local Sanitary Authorities, Educa- 
tion Authorities, Boards of Guardians, Insurance Com- 
mittees, etc. The needless multiplication of officials puts 
the country to unnecessary expense ; and the long delays, 
the overlapping in some directions and the absence of 
control in others, the discouragement of effort, and the 
difficulty of denning responsibility, seriously prejudice 
the public welfare ; while, in the chaos, vested interests, 
ignorance, and apathy find their season. 

Want of knowledge among legislators and adminis- 
trators is in some respects the greatest hindrance to Public 
Health progress, since it not only leads to costly and in- 
effective legislation, but tends to popularise erroneous 
views on the causation and prevention of disease, and 
obscure the real factors which are working. The science 
of hygiene is complex, and when its principles are grasped, 
the applicability of these principles to the populace 
demands further study. The practical effect of a par- 
ticular step may be widely different from the result it 
should have in theory ; and its actual results can often 
only be foreseen by those who have intimate knowledge 
and experience of the conditions and persons to whom it 
is to be applied. But Parliament has no special means 
of acquiring this knowledge, no body of experts from 
which it can obtain information or to which it can refer 
Public Health Bills for criticism. Sometimes it appoints 
a Royal Commission to investigate a particular point, a 
tedious and by no means always satisfactory form of 


procedure ; but often it appears to be believed that any one 
without any special knowledge or experience of the subject 
is competent to legislate upon the highly complex problems 
involved in Public Health measures. A Minister may 
introduce a Bill without any previous expert inquiry into 
its probable effects having been made ; he may or may not 
consult some of the medical officers in the Government 
Departments, and if he does consult them he may dis- 
regard their advice without letting it be known that he is 
acting contrary to their opinion ; the Bill passes through 
a House in which again it receives very little expert or 
scientific criticism, and its administration as an Act is 
entrusted to a Department of the Civil Service in which 
medical and scientific knowledge is only permitted to 
exercise a strictly limited and subordinate influence. 

The result is that gross mistakes are made and huge 
sums spent for wholly incommensurate return. Parlia- 
ment established a vast scheme for sanatorium treatment 
of tuberculosis at a time when investigation of German 
experience alone would have shown that this form of treat- 
ment is of very little value among working classes who 
continue to live under bad conditions ; and in the same 
Act it endeavoured to set up a scheme for penalising 
persons responsible for sickness, which, as will be shown 
in a later chapter, is wildly impracticable. It forgot the 
existence of the Metropolitan Asylums Board, and it 
apparently did not know that maternity may be a cause 
of sickness. The mistake of taking sickness rates as the 
same for men and women was an elementary one which 
should never have been made, for every doctor could have 
furnished information that women, especially married 
women, suffer more from sickness than men ; and though 
there were not sufficient statistics of sickness payments in 
existence to enable a precise actuarial estimate of the 
difference to be made, there were large statistics available 
of medical attendance upon members of Friendly Societies 
from which a very fair approximation of the difference 
could have been obtained. 1 These mistakes were made 

1 Mr. Roberts, the Chairman of the National Insurance Joint Committee, has 
recently given an entirely new and singularly interesting explanation of the way in 
which these two rates came to be taken as the same. Speaking in the House of 


in the Insurance Act, but other errors will be indicated in 
the legislation relating to purity of food, infant mortality, 
and disease, while the errors of omission which permit 
grave abuses to continue unchecked year after year are 
even more serious. 

Another effect of the doubt which Parliament feels in 
its competency to deal with medical affairs is seen in the 
growing tendency to make a broad statement in an Act 
and leave all details to be settled by an administrative 
Department, which thus comes to possess almost legisla- 
tive powers. Parliament lays down that an insured person 
shall be entitled to ' adequate medical treatment,' with- 
out further qualifying the words or indicating their scope, 
and the Department which administers the Act proceeds 
in accordance with official tradition to give them the barest 
possible minimum of effect. The obscurity with which 
an Act may be drafted may also have serious consequences. 
Writing seven years after the passing of the Act for pro- 
viding meals for school children, the Chief Medical Officer 
of the Board of Education says : " The Act of 1906 . . . 
was so worded as to make it at least doubtful whether they 
[Local Authorities] could legally provide children with 
meals on days when the schools were not open." x It is 

Commons on June 20, 1916, he said : " In the case of the women there was no such 
statistical base to go upon. It is true that some facts were alluded to in the 
actuarial report, but they were imperfect ; though they appeared to point to a 
rate of sickness similar to that of the men. Some precautions were taken, and the 
actuaries proposed that there should be a margin of 31 per cent above the figures 
shown, but the House of Commons during the stages of the Bill reduced the margin 
to 24 per cent. It has been proved, especially in the case of married women, that 
the excess is even higher than that, but before this House blames the Government 
for that, I would ask hon. members to recollect what the conditions were in 1911. 
In that year an agitation was raging in the country which, I think, would have 
fixed hold of my proposal to differentiate between men and women as a gross 
injustice. There were no facts available to justify such a differentiation which the 
actuaries could point to ; if in spite of this the Government had decided to treat 
the women with far less liberality and generosity than the men, and if such a 
proposal had been brought down to the House of Commons, I do not think it would 
have survived an afternoon's discussion. That, I think, is the defence on that 

This is a frank admission, which, while it exonerates the actuaries, illustrates 
the loose way in which Public Health measures may be dealt with. The Govern- 
ment apparently knew that their proposals were financially unsound, though they 
did not know precisely to what extent ; but, influenced by a popular agitation, they 
preferred to over-ride expert opinion, keep their knowledge to themselves, and let 
it only be discovered later by experience, to the great embarrassment of Approved 

1 Annual Report for 1913. 


pitiful to think that Parliament should not have made its 
intentions clear in a matter upon which depended whether 
or not many children should go hungry. 

Many grave mistakes will yet be made in Public Health 
legislation, for medicine has far from reached finality, and 
the views held by the highest authorities to-day may be 
proved erroneous to-morrow. Much study is still required, 
and doctrines seemingly established for all time must 
continually be called in question, but we can at least 
secure that at any moment the best knowledge available 
shall serve as the basis of legislation. Our medical men, 
bacteriologists, professors of Public Health, experts in 
sanitation, and scientists do not want to order or control 
the lives of their fellow-citizens ; but the representatives of 
those citizens will do well if they establish a system by 
which they can draw readily from the accumulated wealth 
of medical and sanitary knowledge before they legislate 
for the common good. 



Evolution against disease : typhus ; smallpox ; enteric fever ; scarlet 
fever ; diphtheria ; tuberculosis ; syphilis — The problems of infection — 
The futility of disinfection — The assurance of the layman — The evils 
of exaggerated claims. 

Evolution against Disease 

In succeeding chapters we shall discuss the value of 
the efforts which have been made by the community to 
reduce or eradicate disease. It is important, however, as 
a preliminary step to study the great part which Nature 
herself plays in bringing about these ends, since, if this is 
not done, the mistake may be made of assuming that all 
diminutions of disease have been due to our own efforts, 
and this in its turn may lead to legislative and administra- 
tive action built upon false analogies and wrong inferences. 
Silently, often unobserved, and often not understood 
when observed, Nature has for long ages been increasing 
men's power to fight against the diseases to which their 
environment exposes them ; probably through a process of 
natural selection which results either in an increased degree 
of immunity against the disease, or in an increased capacity 
to recover from the disease when attacked. Various 
aspects of this evolutionary process have been dealt with 
by Metchnikoff, Karl Pearson, and others, and the whole 
subject has been examined in a masterly way by Archdall 
Reid. The process is most easily observable in native 
races, where the influence of Nature has not been overlain, 
or obscured, by the conscious action of the community. 
Among such peoples, diseases newly-introduced may have 
a devastating effect, though these same diseases are rela- 



tively trivial among peoples who have had a long racial 
experience of them. Measles is a deadly disease among 
the Polynesian Islanders, epidemics sometimes decimat- 
ing whole communities : vaccination is highly dangerous 
among the Esquimaux who have had no racial experience 
of smallpox, and die from the effects of even its attenuated 
form. A similar effect is seen in the increased mortality 
from tuberculosis of the negro, or the Kalmuck of the 
Russian Steppes, when brought in contact with civilisation 
in white men's towns. As Archdall Reid has pointed out, 
there is nothing mysterious in the disappearance of the 
Red Man, the South American Indian, or the Caribbean 
before the march of the white man ; they have not died 
by the sword, nor from ' domestication,' but from in- 
ability to resist the sudden invasion of the white man's 
diseases. The same relative lack of resistance is exhibited 
by white men when exposed suddenly to native diseases ; 
the British civil servant, for example, suffering far more 
from malaria in West Africa than the racially-acclimatised 

Broadly speaking, the power of a race to resist a disease 
is proportional to the length of time the race has had 
experience of it ; and there is no doubt that this 
evolutionary process has been going on as much among 
civilised as among native peoples. It has long been recog- 
nised that most infectious diseases tend in course of time 
to ' wear themselves out,' and the decline in virulence or 
extent of tuberculosis, syphilis, and other maladies must, 
in part at least, be attributed to this process. A shallow 
argument has been based upon these observations, viz. 
that our efforts to prevent and cure disease are unsound, 
and that we ought to leave natural selection unimpeded 
to work towards the evolution of a disease-free people. 
But to reason thus is to show entire misconception of the 
relations between heredity and environment in disease. 
Our right course is to study Nature in relation to each 
individual malady, and to make her yield up her secrets. 
Then we shall find that often we can work in co-operation 
with her, and indeed sometimes accelerate her efforts. 
An example has already been given in malaria. Nature, if 


left unaided, would probably in the course of time eliminate 
this disease from the human race ; but science has now 
furnished us with precise knowledge of its causes, and, if 
we can succeed in applying that knowledge sufficiently 
widely, we can probably do in a few years what would 
have taken Nature as many thousands. 

The influence of Nature upon disease is not restricted 
to producing changes in the resisting power of human 
beings. There is good reason to believe that bacteria and 
other pathogenic micro-organisms themselves undergo 
evolutionary processes pari passu, and this further com- 
plicates the investigation of the essential causes and 
tendencies of diseases. Bacteriology is a new science, 
and much has still to be learnt about the changes which 
bacteria undergo even in comparatively short intervals of 
time ; but of the experimental and clinical observations 
there is no doubt. In the laboratory bacteriologists can 
now raise or lower the virulence of infective organisms at 
will by passing them through various animals or subjecting 
them to certain processes. The study of epidemiology has 
shown that a pathogenic organism under natural conditions 
may exhibit a wide range in virulence. Some epidemics 
of a disease are attended by a high death-rate ; others 
of the same disease, under apparently similar conditions, 
cause only a low death-rate, for no reason which we can 
suggest other than a change in the infecting organism 
itself. A severe epidemic of smallpox may be attended 
with a case-mortality of 30 per cent or more, while in 
other epidemics the disease may be scarcely distinguish- 
able from chicken-pox, and in an epidemic in Sydney, in 
1913, among a largely unvaccinated population, there 
was only one death in a thousand cases. Sometimes the 
virulence of a disease exhibits no constant trend, but 
varies from place to place and time to time ; with other 
diseases the virulence may show a steady decline over a 
large area. A good example of the latter is afforded by 
the downward course of scarlet fever in England during 
the last twenty years, and probably on an even larger 
scale by the decline in tuberculosis in most civilised 
countries during the past half-century. 



When two processes towards the reduction of disease, 
viz. the influence of Nature and the efforts of the com- 
munity, are going on side by side, it must necessarily be 
at times very difficult to allocate to each its real share 
in the final result. Of some diseases we can speak with 
considerable assurance : we have little reason to doubt 
that the decline in the mortality from scarlet fever has 
been due chiefly to a natural process, or that the reduc- 
tion of typhoid fever has been brought about mainly by 
our achievements in sanitation ; but of most other diseases 
our knowledge is still too scanty for definite conclusions 
to be drawn. 

The last fact is one which is not generally appreciated, 
with the result that when a disease is observed to decline, 
and when during the period of the decline measures 
have been in force intended to reduce that disease, the 
assumption is invariably made that the decline of the 
disease has been due to these measures ; and therefrom 
the' further conclusion is drawn that similar measures 
applied to other diseases will be equally beneficial. Claims 
which cannot be substantiated scientifically are continu- 
ally made. Ministers when introducing Public Health 
measures in Parliament, and social reformers when urging 
Public Health changes, point with pride to the decline in 
the death-rate, and claim it as the result of sanitary 
efforts ; though if this is the whole explanation, the rise 
in the death-rate which has occurred since 1912, and is 
likely to continue from causes wholly unconnected with 
sanitation, must equally be attributed to some failure to 
maintain these efforts. Similarly the disappearance of 
smallpox is ascribed without doubt to vaccination ; 
typhus has gone because we have cleaned and purified 
our cities ; the reduction of tuberculosis is due to im- 
proved housing, disinfection, etc. ; and the decline of 
infant mortality is attributed to notification of births, 
instruction of mothers, and similar measures. The dis- 
appearance of leprosy alone is not claimed as a result 
of sanitary efforts, probably because it is too well 
known that the disease vanished long before there was 
any effective Public Health organisation in existence, 


and while general conditions were still filthy and in- 

It is true that the standardised death-rate has fallen 
substantially in the last half-century. During the period 
1866 to 1870 it averaged 21*2 per thousand, while for the 
years 1910 to 1914 the average was only 135 per thousand, 
but we cannot be dogmatic as to the causes of this decline. 
We do not know the extent of natural influences, and 
it is possible that modern surgery, which saves many 
thousands of lives annually, has played a larger part than 
sewers. It would be unjust to the memory of Chadwick, 
Farr, Simon, Shaftesbury, and other pioneers to under- 
estimate the value of sanitation. But we now possess 
knowledge which was not open to these men, and we are 
no longer justified in generalising about disease in the way 
which was the only course possible half a century ago. 
We know now that different infectious diseases differ in 
their degrees of infectivity, and in the conditions under 
which they are conveyed to man, and that they demand 
different methods for their prevention. Notification and 
isolation have undoubtedly been valuable means of check- 
ing smallpox, but have been of no use in reducing the 
prevalence of scarlet fever or diphtheria ; and notification 
of tuberculosis has probably done more harm than good, 
since it has created a grossly exaggerated fear of infection 
in the public mind, has increased the difficulties of 
notified persons in getting work, and yet has not com- 
pensated us for these drawbacks by providing statistics 
of any value. Some of these statements are far from 
being in accord with popular opinion, and as they will be 
received with scepticism, it seems desirable to support 
them by tracing the course of the commoner infectious 
diseases in England and Wales during recent years, and 
quoting opinions of those who have closely studied their 

Typhus is a disease which at one time was very prev- 
alent in England and Wales, and its tendency to attack 
crowded aggregates of human beings is shown by its old 
names of 'gaol-fever,' 'hospital-fever,' and 'camp-fever.' 
Until 1850, when Jenner at the London fever hospital 


confirmed the earlier work of Gerhard, Stewart, and 
others, typhus was not distinguished from typhoid fever, 
and it was not until 1869 that the Kegistrar - General 
separated the two diseases in his reports. Accordingly, 
our statistical knowledge of typhus only dates from that 
year. It was believed until recent years that typhus was 
transmitted through the air ; and this was held to be 
supported by the observed fact that close proximity to 
infected persons greatly increased the risk of contracting 
the disease, judges and barristers often catching it from 
infected prisoners in court, while many doctors and nurses 
have died from the disease while attending patients. 
But we now know that the body-louse is the principal, if 
not the sole agent in the transmission of typhus, and 
nearness to an infected person increases the risk simply 
because it facilitates the passage of the louse from one 
person to another. Defective sanitation and bad housing, 
which are always held responsible, are not direct causes of 
the disease, any more than are swampy districts the cause 
of malaria, but only in so far as they militate against per- 
sonal cleanliness and lead to overcrowding. Nor does a 
poor state of health from living in insanitary surround- 
ings appear markedly to predispose towards typhus, for 
doctors and nurses suffer as severely as other classes. 
A writer on the subject many years ago pointed out that 
"close proximity to, and contact with the infected in- 
dividual and his dirty belongings lead with great certainty, 
even under the best sanitary circumstances and in a 
healthy, well-fed people, to an attack of typhus." 1 
According to Sir William Osier, no other disease has 
claimed so many victims among the medical profession. 2 

Typhus did not decline regularly in England and Wales, 
but fell very markedly and abruptly during the decade 
1869-79. Its course since tabulation of the disease began 
is shown in the following table :— 

1 Supplement to Forty-fourth Annual Report of the Local Government Board. 

2 Under war conditions the mortality is often very heavy. Dr. Caldwell, 
Sanitary Commissioner to the American Red Cross in Serbia during the typhus 
epidemic in 1915, states that 160 members of the Serbian medical profession out 
of a total of 340 died from the disease. Doctors and nurses sent by other 
countries suffered as severely; five of the American physicians lost their lives, 
and in one Red Cross unit eleven out of fourteen nurses contracted the disease. 


Mortality from Typhus : England and Wales 






































































* Annual Average. 

It will be noticed that the mortality from typhus fell 
from 4281 in 1869, to 533 in 1879, and it is by no means 
easy to find a satisfactory reason for this large and rapid 
decline. Dr. Brownlee of the Medical Research Com- 
mittee says : "I think the disappearance of typhus was 
" as much due to natural causes as to sanitary endeavour. 
" It is difficult to offer proof of either statement . . . , but 
" the fact that the disease disappeared from the West 
" Highlands and from the West of Ireland at the same time 
" as it died out in England, suggests that some change in 
" the organism was at least of as much importance as the 
" application of sanitary measures." x Dr. Bruce Low 
of the Local Government Board says : " It is not very 
" evident what has caused this very marked diminution of 
" typhus fever in England and Wales. No special measures 
" have been taken against the malady, beyond isolation of 
" cases in hospital and disinfection of dwellings and, in 
" later years, of clothing and bedding. The decrease of 
" typhus fever in this country has, however, followed close 
" upon the march of sanitary progress subsequent to the 

1 " Periodicity of Infectious Diseases," Public Health, March 1915. 




"passing of the Public Health Acts of 1872 and 1875." 1 
The last sentence, though very cautiously worded, might 
be taken to suggest that these Acts had played a part in 
bringing about the reduction, but it is difficult to see that 
this could have been the case. A substantial fall had 
occurred before the earlier of the Acts was passed, and for 
the first few years the working of these Acts was very 
incomplete. It is on record for example that the great 
majority of the Medical Officers of Health first appointed 
were simply part-time general practitioners, who could 
not have had special knowledge of sanitation. Moreover, 
we know that the primary agent in the transmission of 
typhus, the body-louse, is to this day widely prevalent in 
the poorer quarters of all large towns. With so much 
uncertainty as to the causes of the decline, it may be 
suggested that if about 1870 any process of protective 
inoculation against typhus had been widely adopted, it 
would almost certainly have been claimed as the cause of 
the reduction, and we might still be insisting upon the 
observation of such a measure. 

These considerations show that we are dealing with a 
very obscure problem. It is difficult to believe that a 
change in the resisting powers of human beings can have 
occurred in so short a space of time, but the rapid multi- 
plication of bacteria, which compresses many generations 
into a short interval, renders quite conceivable a change 
in the virulence of the organism ; nor is it outside the range 
of possibility that there has been a change in the constitu- 
tion or habits of the louse itself. We have still much to 
learn, but we probably now know sufficient to prevent an 
epidemic of typhus from ever occurring again in this 
country. The disease, too, is one which has ravaged 
armies in the past, and we can justly take credit for the 
almost complete freedom from it of our troops in the 
present war, even under conditions favourable to an 
outbreak ; but the claim, so often made in an eloquent 
peroration, that " the disappearance of typhus is one of 
the greatest triumphs of modern medicine " cannot be 
substantiated by scientific investigation. 

1 Supplement to Forty-fourth Annual Report of the Local Government Board. 


Smallpox has been the subject of long and bitter con- 
troversy regarding the causes of its decline. No reason- 
able person, reading impartially the history of this terrible 
disease, can doubt that vaccination played an appreciable 
part in reducing its prevalence ; but it is open to argument 
whether this precaution is still essential purely as a pro- 
phylactic, though it is of course important during an epi- 
demic among persons brought in contact with the disease. 
When vaccination was first established in this country, 
sanitation was still very defective, clinical knowledge was 
not nearly so great as at present, doctors might easily 
overlook anomalous or slight cases, and the facilities for 
isolation and treatment were wholly inadequate. Under 
these circumstances it was of great value. But we now 
have more skilled diagnosis, and facilities for prompt 
isolation of infected persons and those who have been in 
contact with them. As year by year the proportion of 
unvaccinated persons in the community increases without 
serious epidemics, the opinion steadily grows that rigid 
enforcement of these measures is sufficient to prevent an 
epidemic if the disease is accidentally introduced. Dr. 
Millard, the Medical Officer of Health for Leicester, has 
ably stated the arguments in support of this view. 1 , 

But while admitting the great value of vaccination in 
the past, we cannot ignore the possibility that natural 
influences have contributed to the reduction of smallpox. 
Dr. Thomas Gibson, the Medical Officer of Health for 
Wakefield, says : " The slackening off in the law with 
regard to vaccination which has been a feature of recent 
years, is, I am sure, viewed with considerable misgiving 
by most of us. At the same time, having regard to the 
modifications which diseases appear to undergo in the 
course of time, I am not sure that it is wise to prophesy 
as some do the certainty of a terrible retribution for the 
increasing neglect of vaccination. To refer back to 
typhus for a moment, although that disease was one 
strikingly associated with privation and overcrowding, 
I am not at all satisfied that the improvements in the 
economic and housing conditions of the people have been 

1 The Vaccination Question in the Light of Modern Experience, 1914. 


in themselves sufficiently great and potent to account 
for the very marked reduction in the prevalence of the 
disease. It is more likely that improved sanitation has 
acted as a powerful auxiliary to a natural tendency in the 
disease to die out — call it immunity or what you like, — 
and it is just possible that vaccination has been working 
alongside and augmenting in the process of time a similar 
tendency in smallpox." x 

Enteric fever was responsible in 1874 for a mortality 
of 374 per million living, but the death-rate has fallen 
almost uninterruptedly since that year, and in 1914 it 
was only 46 per million. The decline in this disease is 
perhaps our greatest and most definitely-proved achieve- 
ment in sanitation. Enteric or typhoid fever is probably 
almost solely conveyed by food or water, and the estab- 
lishment of a pure supply of drinking-water has been by 
far the greatest factor in its diminution. During recent 
years we have learnt that certain persons termed ' carriers,' 
who are apparently in good health, but are chronically 
infected with the organisms of the disease, may act as 
centres of infection, particularly if they are employed as 
milkmen, cooks, etc., in the handling of food. The diffi- 
culty of dealing with these persons is very great, but were 
it not for this source of infection, typhoid fever would 
possibly be completely stamped out in England in the 
course of a few years. 

Scarlet Fever. — The death-rate from this disease has 
been steadily and rapidly falling for the last fifty years, 
having been 960 per million persons in England and Wales 
during the period 1866-70, and 63 per million during 
1910-14. There are good reasons for believing that this 
decline has been due mainly to a change in the virulence 
of the organism ; but to examine this point it is preferable 
to deal with a group of the population which has been more 
or less under constant conditions, and to state the mort- 
ality in terms of the number of cases of the disease, since 
this eliminates variations due to its varying prevalence 
from year to year. The cases treated in the hospitals of 
the Metropolitan Asylums Board form a useful unit for this 

1 Public Health, April 1915. 



purpose, and the steady decline in the mortality among 
these cases is shown in the following table : — 

Scarlet Fever : Mortality per cent of Patients treated in 
the M.A.B. Hospitals 


Case Death-rate 
per cent. 


Case Death-rate 
per cent. 















1900 • 


































. 1891 
























It will be noticed that since 1884 there has been an 
almost uninterrupted fall in the case death-rate ; and in 
thirty years scarlet fever has become a less deadly disease 
than either measles or whooping - cough. This change 
has occurred in persons drawn from the same districts, 
living under practically constant conditions and treated 
in essentially the same manner. There has been no great 
medical discovery for the treatment of scarlet fever such 
as has been made in the case of diphtheria, and indeed, in 
uncomplicated cases, there is very little opportunity for 
purely medicinal treatment, the essential conditions for 
recovery being skilful care and nursing ; nor can the 
decline be attributed to improvements in the latter, for the 
high standard of nursing established quite early in the 
Board's hospitals left little scope for advance. It is as 
certain as anything in medicine can be, that the decline in 
the mortality from scarlet fever has been due to some 


change in the infecting organism which has appreciably 
reduced its virulence. 

Diphtheria is another infectious disease which has 
shown a great decline in mortality during recent years, 
but the causes of the decline appear to be very different 
from those which have reduced scarlet fever. Up to 1895 
the case death-rate from diphtheria in the hospitals of 
the Metropolitan Asylums Board ranged from 23 to 59 
per cent, but about that year the modern antitoxin 
treatment which had resulted from the labours of Klebs, 
Loffler, Behring, and others was introduced, and in the 
succeeding years a rapid fall occurred in the mortality, 
which in 1914 was only 7*9 per cent of the cases treated. 
Just as we may take credit for the decline in typhoid fever 
as our greatest sanitary achievement, so we may regard 
the decreased mortality from diphtheria as one of the 
most successful results of purely clinical medicine. 

The question may legitimately be asked : Why should 
not the decline in mortality from diphtheria also have 
been due to a lessening of the virulence of the organism 
which has happened to coincide with the introduction of 
a new treatment, and has accordingly led to the credit 
being given to that treatment ? The answer is that in 
patients who do not receive the antitoxin treatment, the 
disease exhibits a virulence fully as great as that of twenty 
years ago. Further, there is a very marked relation 
between the mortality-rate and the period in the disease 
at which the injection is given ; the earlier the day and 
the shorter the time the bacteria have had to generate their 
toxin, the more potent is the effect of the antitoxin. It 
is certain that if all cases of diphtheria could be treated 
shortly after infection, the mortality would be further 
substantially reduced. 

Tuberculosis. — There is no disease exact knowledge of 
which is so important as tuberculosis, for it is the most 
widespread and deadly affection now existing in this 
country, being responsible for nearly seventy thousand 
deaths in the British Isles every year, and a far larger 
number of cases of sickness. Tuberculosis has exhibited 
a marked decline in nearly all civilised countries during 


the last half -century, and in England and Wales the 
annual death-rate from all forms of the disease has fallen 
from 3479 per million during the years 1851-60, to 1344 
in 1914. There is no reason to doubt that this decline has 
been assisted by diminution of overcrowding, clearing 
away of slums, and enforcement of precautionary measures 
in unhealthy trades ; although the value of the measures 
adopted in recent years, viz. notification of tuberculosis 
and sanatorium benefit, is more open to question. 

The tendency to claim that the decrease in mortality 
has been due to social measures is perhaps more strongly 
exhibited in the case of tuberculosis than in any other 
disease ; nevertheless this claim is by no means fully en- 
dorsed by scientific research, and bacteriologists incline 
more and more to the view that natural processes have 
played a considerable part in bringing about the decrease. 
Professor Hewlett says : " Tuberculosis is diminishing 
" among the white races ; it is, however, spreading among 
" many coloured races. It is to be noted that the decline 
" began long before the germ origin had been demonstrated, 
" and what is more, the rate of decline was almost as great 
" before any administrative measures were taken against it 
" as since." 1 The marked decline in the death-rate from 
phthisis in Edinburgh which followed the establishment of 
the dispensary system was unhesitatingly attributed to 
that system, which accordingly became a model for other 
localities. Unfortunately for this view the death-rate 
in Aberdeen — without any dispensary — fell to a greater 
extent during the same period. Professor Karl Pearson, 
who has very ably analysed these and other statistics 
relating to tuberculosis over a long period, sums up his con- 
clusions by saying: " It seems to me that when we study the 
" statistics of the fall of the phthisis death-rate, when we 
" notice this fall taking place in urban and in rural districts, 
" when we see that it started long before the introduction 
" of sanatorium and dispensary work and that it has not 
" been accelerated by modern increase of medical know- 
" ledge, then we are compelled to regard that fall as part of 
" the natural history of man rather than as a product of his 

1 Manual of Bacteriology, 5th ed., 1914. 


" attempt to better environment." x Professor Karl Pearson 
has argued strongly that an hereditary influence is the 
main factor, those persons who have inherited a predisposi- 
tion towards tuberculosis being particularly liable to the 
disease. Metchnikoff, following the suggestion of Roemer, 
has found increasing support among scientific men for his 
view that the great majority of town-dwellers have already 
suffered from an attenuated form of tuberculosis, and 
have thereby acquired varying degrees of immunity against 
the disease which have helped to bring about the decline. 
After pointing out that " the systematic researches made 
" by Dr. Naegeli and confirmed by other pathologists have 
" demonstrated that nearly all human beings, dead from 
" other causes than tuberculosis, present, in some part or 
" other of their organism, latent and more or less extended 
" lesions due to tuberculosis," Metchnikoff says : " I hold 
" that in addition, to rational hygienic measures, the un- 
" conscious immunisation of the population by the tuber- 
" culous vaccines scattered around us must play an im- 
" portant part in causing the diminution of the annual 
" death-rate due to tuberculosis. . . . Just as the Kalmuk 
" children easily take tuberculosis in the cities when by 
" the side of their European comrades who remain free 
" from it, so persons who come into the great centres of 
" typhoid fever very frequently contract this malady whilst 
" the original inhabitants of the country continue to enjoy 
" good health. . . . These indications suffice to show the 
" great importance of discovering the natural processes by 
" which man acquires immunity against infectious diseases 
" in general and against tuberculosis in particular." 2 

Syphilis is a disease of which we have not much accu- 
rate and reliable statistical knowledge, but according to 
evidence given by numerous witnesses before the Royal 
Commission on Venereal Diseases, there are good grounds 
for believing that it has been declining both in frequency 
and virulence for many years. Older physicians say that 
the terribly severe types of cases met with a generation 
ago are now much less frequently seen, even among patients 

1 Tuberculosis, Heredity, and Environment, 1912. 
2 The Warfare against Tuberculosis, Bedrock. January 1913. 


who have received no treatment ; and the worst forms of 
the disease are encountered among native races. The 
lessened frequency of syphilis is very probably due to 
greater care and cleanliness and a higher moral standard ; 
but the diminished severity must almost certainly be 
attributed to the natural tendency exhibited by so many 
diseases to die out in the course of time. 

This brief summary, which has not attempted to do 
more than touch upon the scientific knowledge relating 
to the natural history of disease, shows that the question 
as to why a disease decreases is often very obscure. Under 
these circumstances the scientific investigator hesitates to 
undertake the thankless task of opposing popular opinion, 
when he can only support his views by scientific arguments 
and statistics which the average person has neither time 
nor inclination to study ; and the layman accordingly 
cannot be reproached for making dogmatic statements 
and jumping to conclusions which are not substantiated 
by science. It might be said that the question is of purely 
academic interest, and that so long as a disease disappears 
it does not much matter whether it be due to a natural 
process or social measures. But if these measures are 
based upon erroneous beliefs they are apt to be wasteful 
and sometimes actually harmful ; their apparent success 
leads to similar measures being applied to other diseases ; 
and they set up false views and. theories which distract 
attention from the real agencies at work. 

The Problems op Infection 

The discovery that infectious diseases are caused by 
the transmission of micro-organisms from one person to 
another has been of incalculable value in the progress of 
medical science. As we have seen, the fact that isolation 
of persons suffering from certain diseases was an efficient 
method of checking the spread of these diseases, was 
observed in remote times. The demonstration of the 
germ origin of disease provided a scientific explanation 
of the observed facts, but it also led to the belief that 
isolation would be an effective method of preventing the 


spread of any infectious disease. We now know that 
this view is no longer tenable, and we have learnt that 
the methods satisfactory for dealing with one disease are 
by no means as suitable or satisfactory for another. In 
the popular mind all infectious diseases are more or less 
alike, and infection through the air is generally believed 
to be the most frequent mode of transmission ; but science 
has taught us that we cannot generalise in this way, and 
has shown us that some diseases are conveyed through 
food and water, some by animals, some by insects, some 
possibly through the air (though this is not proved even 
in the case of tuberculosis), and some only by direct contact 
between man and man ; while in regard to others we 
must frankly admit that we do not know their mode of 

When diseases are governed by such diverse conditions, 
it is obvious that methods of prevention which will succeed 
with one will not necessarily do so with another, and the 
argument from analogy may lead us into serious errors. 
We have for example good reason for believing that prompt 
isolation is a valuable means of preventing the spread of 
smallpox. Almost every year a few cases of smallpox 
occur in this country, generally introduced at the sea- 
ports, and when they are detected, persons suffering from 
the disease are at once isolated, and those who have been 
in contact with them are also isolated or kept under close 
observation. The fact that it is now a good many years 
since an epidemic of any size has occurred, appears to 
show that these measures are sufficient. 

On the other hand, isolation of patients suffering from 
scarlet fever or diphtheria appears to have had no effect 
upon the prevalence of these diseases. Unfortunately 
our statistical knowledge for England and Wales relating 
to the prevalence (apart from mortality) of scarlet fever 
and diphtheria does not go back earlier than 1911, for 
although these diseases were made notifiable in 1889, it 
was not until 1911 that the Local Government Board 
compiled and issued statistics relating to the whole 
country. The following table shows the course of these 
diseases in England and Wales since that year : — 



Notifications of Scarlet Fever and Diphtheria in 
England and Wales, 1911-1915 


Scarlet Fever. 







In Scotland there has been the same upward tendency 
in the prevalence of these diseases accompanied by the 
same marked decline in the case-mortality : in 1914, 
notifications of scarlet fever were 27,321, of which 21,942 
were admitted to hospital ; and notifications of diphtheria 
were 9667, with 7904 admissions. In Ireland, case death- 
rates are not available ; the rates per 100,000 of the popu- 
lation are low for both diseases, but that for scarlet fever 
has risen considerably in recent years. 

It may be said that these figures do not afford a justifi- 
able test of the value of isolation, since some of the patients 
will have been treated at home, and not at the fever 
hospitals ; but this, at most, only applies to the degree of 
isolation, for even when patients are attended at home 
precautionary methods are adopted, the patient being 
isolated in a room, a sheet saturated with carbolic acid 
often being hung outside the door, and the room and 
bedding being disinfected under the instructions of the 
Medical Officer of Health. As regards this point, the 
statistics relating to London are important, since nearly 
90 per cent of cases of scarlet fever and diphtheria notified 
are now received into the hospitals of the Metropolitan 
Asylums Board, and these statistics have the additional 
value of going back to an earlier period than those for 
England and Wales. The following table shows the 
number of cases of scarlet fever and diphtheria which 
were notified from 1890 to 1914 : — 



Notifications of Scarlet Fever and Diphtheria in London 


Scarlet Fever. 















* Annual average. 

It will be seen that compared with the decade 1890- 
1899 there has been some decline in the incidence of both 
diseases, the lowest point having been reached for diph- 
theria in 1910 and for scarlet fever in 1911 ; but since those 
years the numbers have risen steadily, and the high 
figures for 1914 show how far we are from ' stamping 
out ' these diseases. The fluctuations in scarlet fever and 
diphtheria suggest that their prevalence is dependent 
upon some factor or factors, possibly meteorological, of 
which we are still in ignorance. In any case it may be 
noted that although probably a larger proportion of cases 
are treated in the isolation hospitals in London than in 
any other district, the incidence of diphtheria has been 
higher in London for each year since 1911 than in any 
other part of England ; while for scarlet fever London was 
highest in 1914, and was exceeded only by the aggregate 
of County Boroughs during the three preceding years. It 
is clear that isolation is having very little influence on the 
prevalence of these diseases. 

But though the fever hospitals have thus failed in 
their primary purpose of stamping out infectious disease, 
it must be fully recognised that they have been of great 
service in providing efficient care and treatment for a 
large number of persons who would not have been satis- 
factorily looked after at home ; and this is therefore the 
real standard by which the value of the fever hospitals 
must be judged. We must almost certainly abandon the 
hope of stamping out disease through their agency, and 


must look upon them purely as curative institutions just 
as other hospitals. But as soon as this is recognised, 
the question arises whether by restricting admission to 
the fever hospitals to certain types of diseases we are 
making the most economical use of these institutions. 
The criterion for admission is not severity of illness, but 
the fact that the person is suffering from a scheduled 
disease. As regards scarlet fever, we know that a large 
number of beds are occupied by persons who are relatively 
not seriously ill, and who need little in the way of purely 
medical treatment ; on the other hand, the institutional 
provision for general diseases is still very inadequate, 
particularly outside London, and many persons cannot 
obtain admission to a hospital although they may be far 
more in need of institutional treatment than some of those 
in the fever hospitals. We have reason to think now 
that measles and whooping-cough are worse diseases than 
scarlet fever, though we cannot be dogmatic on this point, 
since there is no means of determining their case-mortality. 
Among 3400 cases of measles admitted to the Metropolitan 
Asylums Board in 1913, the death-rate was 11-3 per cent, 
and among 1044 cases of whooping-cough it was 12-8 per 
cent, being thus for each disease approximately ten times 
as high as the death-rate from scarlet fever, but the 
comparison is not entirely legitimate, since the scarlet 
fever admissions were of all types, while those for measles 
and whooping-cough were probably particularly severe 
cases. If milder cases of scarlet fever were treated at 
home, more space would be available for admission of 
severe cases of measles and whooping-cough ; while it 
might be to the advantage of the community as a whole 
to devote some of the fever hospitals to tuberculosis or 
general diseases. It must be remembered that since 
there is a marked seasonal variation with most infectious 
diseases, the prevalence usually rising rapidly during the 
Autumn months, many of the beds in the fever hospitals 
are unoccupied for considerable portions of the year. In 
London the Metropolitan Asylums Board provides 6825 
beds in its eleven hospitals for ordinary infectious diseases, 
but on January 1, 1913, only 4087 of these were occupied. 



These considerations show the need of dealing with 
disease as a whole, instead of making separate provision 
for each malady or type of malady, or class of persons. 
At present we have separate schemes for the treatment of 
tuberculosis, venereal diseases, infectious diseases, diseases 
among the infirm poor, and diseases in school children, 
with the result that some diseases receive more attention 
than their degree of seriousness really demands, while 
others are comparatively neglected. We find one authority 
building or enlarging a hospital or sanatorium, while 
another in the same district has many empty beds. If 
in each district there was a single authority which had 
complete control over all the provision for treatment of 
disease, this provision could be adjusted to meet the needs 
of the community far better than they are provided for 
at present. 

We have digressed somewhat from the main subject 
of this section, which is the problem of infection. In 
tuberculosis this question is of particular importance, 
because a very large part of the modern campaign against 
tuberculosis is founded upon the belief that it is a seriously 
infectious disease. Tuberculosis is notifiable, the Local 
Authorities disinfect rooms and bedding which have been 
occupied by a patient, and Tuberculosis Officers are now 
developing a system of examining persons who have been 
in contact with sufferers from the disease. In the public 
mind the belief is firmly established that tuberculosis is 
readily transmitted from one person to another, and that 
prevention of infection is the great weapon against the 
disease. It has even been urged that tuberculous persons 
should be segregated from the general community or 
placed under restraint ; the Vice-Chairman of the Lanca- 
shire Insurance Committee, for example, writes : "So 
long as consumptives are permitted freedom to live and 
move without restriction, so long will there exist an active 
agency spreading the disease and negativing all the efforts 
otherwise made to combat it." 

We have still a great deal to learn about tuberculosis 
and infection, and a dogmatic attitude is unjustified ; yet 
reflection will show that the infectiousness of tuberculosis 


must be of quite a different order from that of scarlet 
fever, diphtheria, or smallpox, and is probably more com- 
parable with infection by the organisms of pneumonia, 
or the ordinary pyogenic or pus - producing organisms 
which have never given rise to popular fear of transmis- 
sion from man to man. We know that healthy persons 
can expose themselves continually to the risk of infection 
without acquiring the disease ; doctors and nurses in 
sanatoria associate freely with patients for years and 
yet rarely develop tuberculosis ; and it is not even thought 
necessary in the wards of general hospitals to separate 
tuberculous cases from other patients. Dr. Goring has 
investigated the incidence of tuberculosis between husbands 
and wives where, presumably, the greatest opportunity 
for infection exists, and he finds that in the poorer 
classes there is no greater chance of the mate of a tuber- 
culous person being tuberculous than any other person. 
Among the wealthier classes the proportion is slightly 
greater, probably due, as Professor Karl Pearson has 
pointed out, to selective mating, an influence only likely 
to operate among educated people. 1 Sir Hugh Beevor, 
physician to the City of London Hospital for disease of the 
chest, protesting as far back as 1892 against exaggerated 
statements of the infectivity of tuberculosis, said : " The 
" term ' infection ' is too loose a term to apply to both 
" measles and tuberculosis. When its use does damage to 
" the workman's prospects it is perpetrating an injustice 
" upon him. When we see the poor results in the isolation 
" of infective fevers by hospitals for fever, those who rank 
" tubercle as most highly infectious must seriously doubt if 
" it is a right policy to apply such a system to tubercle. . . . 
" I earnestly hope that the medical profession at large will 
" not encourage the public to avoid their tuberculous fellow- 
" creatures. ... I would urge you as the educators of the 
" public in these matters distinctly to let it be known that 
" tubercle is not highly infectious. State that it is not 
" a disease that requires isolation, and that only under 
" certain quite exceptional conditions does it appear to be 
" infectious at all. Insist that healthy people enjoy extra- 

1 Op. cit. 


" ordinary immunity, that fresh air and open windows are 
" the great armour against its attacks." l 

Finally, it may be noted that the Royal College of 
Physicians has thought it desirable to issue a special report 
on the infectivity of tuberculosis in order to counteract the 
excessive fear of infection by the disease which exists 
among the public. 2 

We may consider another aspect of the question. The 
bacillus of tuberculosis appears to be so ubiquitous that 
it seems probable that all town-dwellers at all events 
receive the organism again and again into their lungs 
or alimentary system. If the bacilli are air-borne, we 
have only to consider the condition of the streets to realise 
the frequency of opportunities for infection ; and if they 
are conveyed by food we may note that something like 
10 per cent of the samples of milk analysed contain the 
bacilli of tuberculosis, and everywhere we see pastry, 
sweets, and other eatables exposed for sale in shops thronged 
with passers-by, or exposed to dust from the streets. Even 
the opportunities for almost direct infection are not rare. 
It is a common practice for a shop assistant to moisten his 
finger in order to take up a paper bag, and blow into the 
bag to open it before he puts an article of food into it ; 
a railway clerk will often hand out a ticket moist with 
saliva, and a lady may be seen to place this ticket straight 
in her mouth while opening her purse. Public telephones, 
drinking-fountains, and the practice of licking stamps 
and envelopes, are other conceivable channels of infection. 
Finally, it may be added that many of our domesticated 
animals suffer from tuberculosis. It is clear therefore 
that if tuberculosis were infectious to anything like the 
degree exhibited by the ordinary infectious fevers, and 
the disease resulted simply from the entry of the bacilli 

1 The Problem of Infection and Immunity in Tuberculosis. An address delivered 
before the West Somerset Branch of the British Medical Association. 1902. 

2 The resolution of the Royal College which preceded the issue of the report was 
as follows : " That in view of the exaggerated fear of the infectivity of pulmonary 
tuberculosis entertained by the public, the consequent unnecessary disabilities 
imposed upon sufferers from the disease, and the opposition raised in many places 
to the establishment of institutions for its detection and treatment, a reassuring 
statement with regard to the degree of danger attaching to contact and communi- 
cation with tuberculous persons oe prepared by the College and issued in its name 
at an early date.'" 


into the system, the whole population would probably be 
swept away. 

Why then do some people exhibit the disease in severe 
form and others not ? The answer is that it depends much 
less upon infection than upon the power of resistance of 
each individual to prevent that infection gaining a hold on 
his system when the bacilli are swallowed or inhaled. As 
we have seen, it may be that the great majority of town- 
dwellers have actually been infected with the disease and 
have thereby acquired partial immunity, and it would 
appear that this infection occurs quite early in life. In- 
vestigations made by many observers among children by 
means of the Von Pirquet reaction — a very delicate test 
for discovering the disease — have shown that over 90 
per cent of children have already suffered from tuber- 
culosis. It is possible that tuberculosis is really a disease 
of childhood, like measles or whooping-cough, but that in 
early years it is a comparatively slight affection, the true 
nature of which is rarely recognised. But while these 
questions are uncertain, there is no doubt whatever about 
the environmental factors which lessen resistance. We 
know that a healthy person livjmg in a healthy environment 
is unlikely to develop the disease even though frequently 
exposed to infection, and we know that the disease flourishes 
among those who are overcrowded, breathing foul air 
and insufficiently fed. Instances are sometimes brought 
forward of a number of persons living in the same area or 
street or even house who have developed tuberculosis, and 
it is claimed that these illustrate the danger of infection. 
It may be literally true that these persons have infected 
each other, but the reason why they have acquired the 
disease is almost certainly that the powers of resistance of 
all of them have been reduced by the same bad surround- 
ings. On theoretical grounds fighting the disease by dis- 
infection is sound, inasmuch as if there were no tubercle 
bacilli there would be no tuberculosis ; but the occasional 
disinfection of a room, and the removal of a few cases to 
hospital or temporarily to sanatoria, are probably as 
effective as would be efforts to keep dry on a rainy day 
by wiping the paving-stones. The modern belief in the 


dangerous infectiousness of tuberculosis is diverting atten- 
tion from the main cause of the continuance of the disease, 
which is a bad environment. This influence was well 
known long before the tubercle bacillus was isolated, 
but efforts to reduce it seem now to take the second place, 
and attention is concentrated on prevention of infection. 

It may be noted that many of the arguments for attack- 
ing tuberculosis by destroying the bacilli can be applied 
to all microbic diseases. Pneumonia, for example, re- 
sembles tuberculosis in many respects. It is a bacterial 
disease, it is far more prevalent in urban than in rural 
areas, and susceptibility to it is increased by exposure, 
under-feeding, alcoholism, and other influences tending 
to lower vitality. But no fear of infection by pneumonia 
exists in the public mind, notification is not required, and 
the Medical Officer of Health does not disinfect rooms 
which have been occupied by patients or examine 
' contacts.' 

Similar problems and uncertainties arise with other 
infectious diseases. Dr. Hamer, the Medical Officer of 
Health to the London County Council, has discussed the 
etiology of typhoid fever and has shown that some at least 
of the commonly accepted views of its modes of trans- 
mission cannot be regarded as scientifically proved. 1 He 
has also described the history of a girl, known to* be a 
diphtheria ' carrier,' who was kept under observation for 
six years, but to whom no outbreak of the disease could 
be attributed ; a case which raises doubt whether carriers 
form an important factor in the spread of diphtheria. 2 

There is reason, moreover, to believe that the methods 
of fumigation so widely employed are entirely useless to 
disinfect rooms. Dr. Walcott, the State District Health 
Officer for Massachusetts, has described a series of experi- 
ments, extending over more than a year, which he and his 
staff made to test these methods. They smeared pieces 
of cotton wool and other materials with infective material 
from the noses, throats, and ears of persons in the con- 
tagious diseases wards and from suppurating wounds in 
other wards, and put these on the floor, the table, chairs, 

1 Annual Report for 1914. 2 Annual Report for 1915. 


mantelpiece, etc., of a room at various elevations, a control 
series being placed in another room. The room was then 
fumigated with every known method of fumigation, for 
example, sulphur candles, sulphur powder, formaldehyde, 
etc., and all proprietary remedies. The room was then 
sealed up and left for periods varying from 24 to 72 hours. 
It was found that these methods had no consistent effect 
upon the cultures used. " In one case of a proprietary 
preparation where one candle was guaranteed to kill every 
germ in a given room we made a little shrine of several of 
these candles and put the inoculations in the centre, and the 
germs lived happily through the experiment." * 

As a result of these experiments fumigation has been 
abandoned by the Public Health authorities in New York, 
Boston, and other American cities 

The Assurance op the Layman 

The object of discussing somewhat fully in the preceding 
pages the factors which influence infectious diseases has 
been to show that obscurity and doubt exist on many 
points of fundamental importance. Scientific men hesitate 
to distinguish between the influence of nature and the 
influence of social effort ; they are often uncertain of the 
methods of transmission of diseases, and they cannot be 
dogmatic as to the best ways of eradicating these diseases. 
More research is required in every direction, not only 
medical but sociological ; and a humble though hopeful 
attitude is the only one which befits the scientific investi- 
gator. But we find no echo of this doubt in the utterances 
of our Ministers and legislators, who prepare and carry 
through vast schemes for the lessening of disease. The 
entire fall in the death-rate is boldly claimed as a result 
of legislative and administrative measures, and the disap- 
pearance or diminution of every disease is attributed to 
similar efforts. In an ordinary person these errors would 
not seriously matter, but when made by some one in high 
authority they may lead to the adoption of a wrong and 
costly policy. Since the main object of this book is to 

1 Boston Medical and Surgical Journal, March 9, 1916. 



establish the case for putting our Public Health affairs 
in the hands of those who have real knowledge of the sub- 
ject, it is necessary to justify this statement by quoting 
views which have been expressed by persons in authority. 
Many instances will be given in succeeding chapters, but 
here, for example, we may quote from an address on Public 
Health made by the Right Hon. John Burns as Presi- 
dent of the Local Government Board at the International 
Congress of Medicine in 1913, to an assemblage containing 
many of the most learned and distinguished medical men 
from all civilised countries. The right hon. gentleman 
said : — 

When speaking of the marvellous reduction that has taken 
place in the death-rate in this country, one is perhaps too apt to 
remember only social and sanitary progress as the explanation of 
this great change. My address to you to-day may, I trust, serve 
to show the appreciation by the public of the fact that to a very 
large extent humanity is indebted for the saving of life and of suffer- 
ing that has occurred, to the vast improvements in the science of 
cure as well as of prevention of disease. 

The Past Saving of Life. — Some conception of the progress 
already secured by the application of science, especially medical and 
sanitary science, to the problem of healthy living — and I trust at 
the same time to further triumphs on the part of your profession — 
may be given by the comparison to which I invite your considera- 
tion of the average experience of England and Wales during the 
three years 1909-11 as compared with its experience during three 
years based on the average experience of 1871-80. In the three 
years 1909-11, 1,529,060 deaths occurred in England and Wales. 
This number is 772,811 fewer than would have occurred had the 
average death-rate of 1871-80 held good for these three years. The 
saving of life in three years under special diseases is set out below : 

Smallpox 25,463 

Measles 7,824 

Scarlet fever 69,974 

Whooping-cough ..... 30,884 

Fevers (typhus, enteric, etc.) .... 45,339 

Puerperal fever ...... 3,941 

Diarrhoea, dysentery, and cholera . . . 32,996 

Pulmonary tuberculosis .... 114,799 

Other tuberculous diseases .... 36,338 

Total saving on these diseases . . . 367,558 

Nearly half the total saving has occurred under the heading 


of the diseases enumerated. If we take the whole of the thirty-two 
years, 1881 to 1912, and consider the saving of life during this 
period, the figures are truly colossal. The saving of life represents 
a population which is nearly equal to the total population of London 
or Australia or of Ireland and more than that of Switzerland. 

How has the saving of life already achieved been secured ? 
No complete answer can be given in a few sentences, and perhaps 
my best plan is to proceed by examples, drawing inferences from 
the historical facts of medicine which are open to the layman as 
well as to the doctor. 

The speaker then dwelt upon the work of Howard, 
Elizabeth Fry, Sadler, Oastler, Shaftesbury, Dickens, 
Owen, Kingsley, and particularly Chadwick and South- 
wood Smith ; and he referred to the beneficial work of 
factory inspectors, medical officers of health, and sanitary 
inspectors in laying the foundations of national health. 
He continued : — 

Typhus Fever. — The history of typhus is a romance in sanita- 
tion, from which the principles and practice of preventive medicine 
could be adequately taught. It occurred under conditions of dirt 
and overcrowding ; but, apparently, it arose only by direct infec- 
tion from person to person. It was spread like smallpox, by 
vagrants from parish to parish, repeatedly brought by them from 
Ireland to England, and it was not brought under control until the 
migrations of vagrants had been limited, the sick had been segregated 
in hospitals from the healthy, ' contacts ' had been kept under 
adequate supervision, and the houses harbouring the disease had 
been disinfected and the vermin therein destroyed. In many 
instances the courts and alleys, the favourite lurking-places of the 
disease, were also swept away. Consider the following figures : 
In the ten years 1871-80, in Ireland, 7495 deaths were returned 
as due to typhus fever ; in the three years 1909-11 the number 
had fallen to 143. In England and Wales, in the ten years 1871-80, 
13,975 deaths were caused by typhus fever ; in the three years 
1909-11, with a much larger population, the number was 30. . . . 

Stages in Registration of Disease. — The history of registration 
of disease is inseparably associated with that of public health. . . . 
You will, I think, agree with me that the most important extension 
of the principle of notification has been in regard to tuberculosis. 
The knowledge that this disease is communicable, and the im- 
portance, even apart from the fact of communicability, of having 
exact knowledge of its special haunts, and of its prevalence in 
different industries, and among the poor living in crowded streets 
and courts, have enabled me step by step by means of Departmental 


Orders to apply the principle of compulsory notification to all forms 
of this disease. . . . 

Tuberculosis is the one disease in which the fact that measures 
of treatment and of prevention are to a large extent identical is 
becoming fully realised. . . . Improvements in housing, progress in 
average social conditions, higher nutrition, all have doubtless borne 
their share in bringing about this great reduction in tuberculosis. 
More cleanly habits of the people must be given a large share in 
securing the result. The habit of indiscriminate spitting, although 
still prevalent, is much less so than in the past. The standard of 
domestic cleanliness has improved, and this must have cleaned out 
many of the former centres of infection. Even more importance 
must be attached to the diminished overcrowding of bedrooms. . . . 
The proportion of the total population in England and Wales living 
in rural districts has decreased from one-half to less than a quarter 
between 1851 and 1911. It is evident, therefore, that some import- 
ant influences have been at work counteracting the effect of urban 
conditions as a whole on tuberculosis. Among these, important 
place must be given to the hygienic effect of the stay for months 
in an infirmary or hospital of a high proportion of the total con- 
sumptive population, at the most infectious and helpless periods 
of their illness. At the present time the prospect of complete 
control over tuberculosis is more promising than ever before. Not 
only is public administration, with its magnificent past effect on 
tuberculosis, becoming increasingly efficient ; but the National 
Insurance Act happily has given further important means of effec- 
tive attack against this disease. . . . These schemes ensure early 
diagnosis, prompt treatment, and the removal of sources of in- 
fection, by adequately linked-up measures of domiciliary treat- 
ment, and of treatment at dispensaries, hospitals, and sanatoria. 

In giving these illustrations of what medicine and the sanitary 
service of the country have accomplished, my survey has neces- 
sarily been incomplete. Not only is there a marvellous record for 
typhus and enteric fever, and for tuberculosis, but also for the 
diseases and accidents for which medical aid is required, and to a 
less extent for puerperal fever. A still more striking illustration 
could be found in smallpox, and even measles and whooping-cough 
in recent years appear to be losing some of their power under the 
influence of the child-welfare work which is gradually becoming 
systematised in many sanitary areas. . . . The saving of life in this 
country has not been confined to the diseases ordinarily regarded 
as preventable and curable. Even cancer, if only recognised and 
treated at an early stage, and when accessible to the surgeon, loses 
a portion of its terrors ; and it cannot be that the concentration 
on investigation of this disease in nearly every civilised country 
will fail during the next few years to add it, like tuberculosis, to the 


diseases doomed to insignificance if not actual annihilation. ... I 
have not time to speak of the improvement in infant and child 
mortality which has been realised in recent years thanks in large 
measure to the active work undertaken by the officers of sanitary 
authorities, acting in co-operation with voluntary associations. 

When criticising this speech, it must be borne in mind 
that the speaker was not a medical man, and that he was 
not appointed to his position in consequence of any special 
knowledge of medicine or hygiene. It is indeed a com- 
pliment to Mr. Burns to recall that he was first made a 
Cabinet Minister in recognition of his life-long devotion to 
the interests of labour. Any comments of an adverse 
nature, therefore, are not directed at the right hon. gentle- 
man, whose lofty aims have always been manifest, but at 
the system which, in order to place at the service of the 
country the advice of one who has an intimate knowledge 
of the conditions of the working classes, can only do so 
by putting him in supreme charge of a Department for 
the administration of which he has had neither training 
nor experience. The Public Health work of the Local 
Government Board can only be carried out efficiently 
under the headship of one who has either a profound 
knowledge of Public Health, or has received a scientific 
training which will enable him to study and appreciate the 
scientific work which has been done by others. And this 
speech of Mr. Burns's shows that after nine years of office 
he was still quite out of touch with scientific medicine. 
From beginning to end there is no sign of any recognition 
that natural causes may have played a part in " saving " 
the large number of lives indicated. Nature is ruthlessly 
elbowed aside, and the whole reduction of every disease 
is boldly claimed as a result of sanitary progress and cura- 
tive medicine. The reading of history is remarkable. 
The disappearance of disease is ascribed to measures 
which, if they were taken at all, were taken only on a very 
limited scale, and to the abolition of evils which are still 
rampant in our midst. The picture given of the steps 
taken to prevent typhus is directly negatived by the state- 
ment of Dr. Bruce Law, himself an officer of the Local 
Government Board. The " stay for months in an infirmary 


or hospital of a high proportion of the total consumptive 
population at the most infectious and helpless periods of 
their illness " is considered to have played an important 
part in bringing about the decline in tuberculosis, yet this 
disease has been falling steadily for sixty years, and even 
to-day, in spite of the great addition made under the 
Insurance Act, the provision for institutional treatment 
is notoriously inadequate. The sanatorium treatment of 
tuberculosis is extolled, though investigation would have 
shown the speaker that it had been almost useless among 
the working classes in Germany, and experience is showing 
equally in this^country that it is of little value without per- 
manent change of environment. Measles and whooping- 
cough are roped in with the other diseases which are 
losing part of their terrors, though very little has been 
done in the way of providing public treatment for these 
maladies. Prevention of infection is regarded as the most 
potent weapon in the attack on disease. Finally, though 
the effect of urbanisation in increasing tuberculosis is 
mentioned, there is no indication that the speaker realised 
that this influence runs through the whole gamut of 
disease. In the two succeeding chapters we shall see that 
infant mortality, defects in school children, and sickness 
rates and mortality from nearly all diseases, are all far lower 
in rural than in urban environments. Whatever may be 
the reason for this difference, urbanisation is the overwhelm- 
ing factor in the causation of preventable disease, and it 
links up the problem of securing a healthy people with the 
problems of the land. The principles and practice of pre- 
ventive medicine are not to be learnt from the ' romance ' 
of the history of typhus, but from a close study of the 
effects of urbanisation and of the still undiscovered ultimate 
causes of those effects. To omit reference to this factor, 
except in regard to one or two diseases, in a speech which 
surveys the whole field of Public Health, is to suggest 
that its profound and widespread influence has not been 


The Evils of Exaggerated Claims 

The dogmatic attitude in regard to disease has many 
undesirable results. In a democratic country Public 
Health efforts can never go very far in advance of public 
opinion, and consequently it is exceedingly important 
that that opinion should be founded upon exact know- 
ledge, or upon the best knowledge obtainable at the time. 
But the science of Public Health is vast and complex, and 
the average man has neither the time nor the training to 
study statistics and literature himself. He is obliged to 
take his conclusions ready-made from others, and he 
accepts, as reliable, statements made by a person in high 
authority, particularly if they coincide with his precon- 
ceived views. These statements go out to Borough 
Councils, Education Authorities, and social reformers, 
where they are quoted in argument, serve as a basis for 
local administrative action, and help to establish public 
opinion. Secondly, exaggeration of the ' achievements ' 
of Public Health administration leads to a glossing over of 
the evils which still exist, paints a wholly inaccurate 
picture of the real state of the national health, and creates 
an undue optimism for the future. Dr. Pangloss returns 
from the pages of Voltaire to tell us once more that 
" everything is for the best in this best of all possible 
worlds," and with Kipling we feel that — 

By the rubbish in our wake, and the noble noise we make, 
Be sure, be sure, we're going to do some splendid things. 1 

1 "Road Song of the Bandar-log." 



The ' natural ' rate of infant mortality — The avoidable loss of infant life 
hi the United Kingdom — Infant mortality in town and country — The 
possible causes of infant mortality : poverty ; defective sanitation ; 
infectious diseases ; artificial feeding ; industrial employment of 
mothers ; lack of attendance at birth — Maternal ignorance — Adverse 
pre-natal conditions — The effect of smoke and dust — The pathological 
causes of infant mortality — Deaths from ' developmental conditions ' 
Still-births — The fall in infant mortality in recent years — Infant 
mortality in Bradford — The need for further research. 

The ' Natural ' Rate of Infant Mortality 

Infant mortality is measured by the number of deaths 
under one year of age per thousand births, still-births 
being excluded from both figures. Under the best circum- 
stances a certain number of infants are bound to die in the 
first year of life, for the young of all species are subjected 
to special risks, and sometimes Nature herself does not 
build well enough to enable the tiny spark of life to sur- 
vive. We cannot determine precisely what this ' natural ' 
death-rate is, since we cannot study mankind under purely 
natural conditions, but we can ascertain the lowest rate 
among communities or classes of some size, and this is 
the essential first step in an investigation of anfant 
mortality, for without such a minimum there is no means 
of measuring the avoidable loss of life occurring among 
other groups. We will examine for this purpose, first, the 
rates of infant mortality among different social classes, 
and, secondly, the rates in different types of areas, which 
is the more important investigation for practical purposes. 
In his Report for 1911, the Registrar-General included 
a table showing the rates of infant mortality in different 



classes according to the father's occupation ; and in a 
group of these classes consisting of doctors, solicitors, 
army officers, clergymen, and others of the professional 
class, but including with them woodmen and foresters, 
the infant mortality rate was 42 per thousand births, 
which may be contrasted with the rate of 171 among 
general labourers, ironworkers, scavengers, and hawkers. 
This figure would appear to show that a death-rate of 
much over 40 need not occur, but the inference is not of 
much practical value so long as it is drawn from these 
facts, for it does not tell us why the rate is so much lower 
in the professional classes ; whether, for instance, it is due 
directly to their wealth enabling them to obtain more 
food, better medical attendance, etc., or whether, as a 
result of that wealth, they live on the whole in a better 
environment. Moreover, the professional classes do not 
form a community, and in any circumstances we could 
never place the whole population under their conditions 
as regards wealth, though it will be shown that we may 
reasonably hope to do so as regards health. 

The best guide for practical purposes is afforded by 
the lowest rates found in actual communities which are 
of sufficient size to eliminate variations due to accidental 
causes. 1 The following table shows the larger districts in 
the British Isles which had the lowest rates of infant 
mortality in 1914 : — 

1 The extent to which inferences may be built up by social reformers upon the 
most inadequate of statistics is well illustrated by the sweeping conclusions which 
have been drawn from the experience of infant life in the small French commune 
of Villiers le Due. It has been claimed as a wonderful achievement that for ten 
years together — 1892 to 1903 (we are not told about more recent years) — the 
infant mortality rate in the commune was zero. This absence of deaths has been 
ascribed to the regulations for the protection of infant life in the district, which 
have been widely quoted in this country and even fully described in a Milroy lecture 
before the Royal College of Physicians. But the fact that the total number of 
births during the ten years was only 5-4 is never mentioned, and rates per thousand 
are worked out on a yearly average of less than 6 births. There are no doubt many 
tiny English villages which can show a record as good as that of Villiers le Due, 
while, as far as numbers are concerned, the experience of Crowle in Lincolnshire, 
in 1914, with 75 births and no deaths, is better. 

Since the above was written, the writer has ascertained that during the ten 
years 1906 to 1915 there have been 43 births in the commune of Villiers le Due, 
with 4 deaths. Thus during this period the infant mortality rate has been over 
90 per thousand births. Taking the two periods together we get a rate of 46 per 
thousand births, which is not an unusual rate for an ordinary healthy rural 



Lowest Eates of Infant Mortality, 1914 



Deaths under 1 year 
per 1000 births. 


Berkshire — Rural Districts 



Oxfordshire „ 



Wiltshire ,, 



Buckinghamshire „ 



Herefordshire ,, 



Cambridgeshire „ 



Somersetshire „ 



Devonshire „ 



Dorsetshire „ 



Suffolk, West 



Sussex, East „ 



Huntingdonshire „ 



Westmoreland „ 



Essex „ 



Northamptonshire „ 



Surrey „ 



Sussex, West „ 







Argyllshire .... 



Ross and Cromarty . 



Kirkcudbright .... 







Roscommon .... 
























This table shows that large numbers of people in 
widely separated parts of the country and subjected to 
very different climatic conditions are living under con- 
ditions which do not give rise to an infant mortality rate 
of more than from 40 to 60 per thousand births, and it 
could have been much extended by including smaller 


districts. It is certain that even these figures could be 
lowered, and we shall see later that probably any rate over 
30 should be regarded as preventable, but provisionally 
we may take 50 deaths under one year per thousand 
births as the standard by which excess of infant mortality 
can be measured. 

The Avoidable Loss of Infant Life in the 
United Kingdom 

We are now in a position to estimate the annual loss 
of life in the United Kingdom which appears to be due to 
preventable causes. The total number of births registered 
in 1914 was 1,101,836, and the number of deaths under 
one year of age was 114,591, giving an infant death-rate 
of 104 per thousand births. If this rate had been 50 per 
thousand the number of deaths would have been 55,092. 
Thus we see that nearly sixty thousand lives were lost 
owing to presumably preventable causes. Nor is this 
loss the full measure of the evil, for as Dr. Newsholme has 
shown, a high infant mortality rate is invariably associated 
with a death-rate above the average at succeeding ages 
at least up to twenty years. If but a quarter of this 
number of deaths were caused by a sudden famine or 
pestilence which brought them prominently into notice, 
the most strenuous national efforts would be made to 
abate the evil. It is because they are scattered, and 
because we are so familiar with the evil, that we fail to 
realise the magnitude of the annual tragedy. 

Infant Mortality in Town and Country 

Having seen where infant mortality rates are lowest, 
we must now note where they are highest, and these 
localities are shown in the following table, together with 
the rates in some of the leading cities. It should be 
observed that the rate for a whole town is as a rule 
appreciably lower than those in the worst districts of the 
town, which in some industrial cities are as high as 200 or 
more per thousand births. 




Highest Rates oi 


[nfant Mortality, 1914 

Town or District. 


Deaths under 1 year 
per 1000 births. 

England and Wales 

Ashton-under-Lyne . . . 45,494 








Gateshead . 





















St. Helens 















South Shields 






Sheffield . 






Leeds . 






Bradford . 











Paisley 86,593 









Dublin — Registration Area . > 434,678 


Belfast 408,553 


In London the infant mortality rate in 1914 was only 
104, but the general rate is reduced by the low rates in 
the ring of outlying districts. In the central parts the 
rates range from 120 to 140 per thousand births. 

The difference between urban and rural death-rates 
is one of the most constant and striking features in the 



distribution of infant mortality, and affords a strong clue 
to the real causes of these deaths. We may note the 
effect of urbanisation on a large scale in the following table, 
given by the Registrar-General for Ireland, showing the 
rates in ' Civic Unions,' which are districts containing 
towns with a population of 10,000 or upwards, and the 
rest of Ireland. 

Distribution op Infant Mortality in Ireland, 1914 


Population (1911). 

Deaths under 1 year 
per 1000 births. 

Total ' Civic Unions ' 
Kemainder of Ireland 

Whole of Ireland 





The influence of rural conditions is also seen on a large 
scale in countries where a considerable proportion of the 
population are engaged in agriculture or stock-raising. 
For instance the infant mortality rate for the latest year 
available was 51 in New Zealand, 65 in Norway, 71 in 
Australia, 71 in Sweden, and 78 * in France. 

An analysis of the rates in France in 1912 is given in 
the following table : — 



Deaths under 1 year 
per 1000 births. 

Towns of 5000 inhabitants and 

Remainder of France 

All France .... 






It should be noted that 1912 was a year of exceptionally 
low infant mortality in nearly all European countries. 

The statistics for England and Wales as a whole do 
not show such striking differences as those presented by 
Ireland and France, the rates for 1914 having been 121 

1 This figure is not strictly comparable with British rates, since in France 
deaths occurring before registration, i.e. before the third day, are regarded as 
still -births. 


in the aggregate of County Boroughs, 99 in other Urban 
Districts, and 85 in Eural Districts, but this is due partly 
to the fact that the distinction between ' urban ' and 
' rural ' for registration and statistical purposes does not 
always conform to the differences in the meanings of these 
words as commonly understood. Since we shall have 
occasion in this and the succeeding chapter to quote 
frequently urban and rural statistics, it is important to 
pay some attention to this point. In the figures previously 
given for Ireland and for France, definite lines of division 
were taken based upon population. But in England and 
Wales the Kegistrar-General, when classifying deaths 
according to ' Municipal Boroughs,' ' Urban Districts,' 
and ' Rural Districts,' is unable to proceed on this basis, 
since the distinction between these areas is often a matter 
of history or convenience, and may have little relation to 
the population or real character of the district. In 
consequence we find included in urban districts a 
large number of Municipal Boroughs with populations 
of less than 5000, * and a still greater number of Urban 
Districts with populations ranging from 5000 to 1000 or 
even less, many of which are really rural villages. On 
the other hand we find included in Rural Districts large 
villages which have gradually grown up and perhaps 
coalesced with adjacent villages, until they really form a 
town of some size, though for registration purposes each 
still forms a Rural District. This development has been 
particularly marked in the northern counties of England, 
where great mining areas such as those of Chester le Street 
in Durham, with a population of 67,667 and an infant 
mortality rate of 140, and Easington in the same county, 
with a population of 64,935 and an infant mortality rate 
of 159, contain large densely crowded villages with very 
little of a really rural character about them. A picture 
of the conditions in one of the so-called rural areas is given 
on p. 91. For these reasons the statistical difference 
between ' urban ' and ' rural,' when applied to the whole 
of England and Wales, does not correspond entirely to real 

1 E.g. Wallingford, Buckingham, Wokingham, Fowey, Helston, Penryn, 
Okehampton, Lyme Regis, Chipping Norton, Bishop's Castle, Lymington, Romsey, 
Southwold, Arundel, Malmesbury, Beaumaris. 



differences, and the general effect is to lower the urban 
death-rate and raise the rural death-rate. In the succeed- 
ing pages, therefore, most of the comparisons will be made 
between the County Boroughs of the north of England 
which are the great centres of industrialism, and the Rural 
Districts of the south which do actually conform to their 
description. The objection may be made that this com- 
parison does not eliminate climatic differences, but we 
shall see later that as regards infant mortality, climatic 
differences appear to exert little effect, the rates and causes 
of deaths being essentially the same whether we take the 
south of England or the north of Scotland, and there is 
no reason to doubt that this is equally true of deaths 
at later ages. It is however more convenient to deal 
with the statistics of the south of England than with those 
of rural Scotland or Ireland since they are more complete. 1 
The rates of infant mortality in the areas defined are — 

County Boroughs of the North . . .130 

Rural Districts of the South ... 66 

The preceding tables have shown the extreme difference 
between purely rural and strongly urban districts. It is 
important to notice however that low rates of infant 
mortality may be found in towns, even of some size, in 
which there is little overcrowding or industrialism, with 
consequent purity of air and freedom from smoke — 
" country " towns as many of them would be called — 
though even in these the rates are generally higher than 
in the purely rural districts. The following are examples of 
such towns with their rates of infant mortality in 1914 : — 

Bath . 


Tunbridge Wells . 




St. Albans . 


Canterbury . 






Folkestone . 




Worthing . 




Colchester . 










Poole . 






East Ham . 


1 In future references ' North ' includes Cheshire, Lancashire, Yorkshire, Dur- 
ham, Northumberland, Cumberland, and Westmoreland ; ' South ' includes Surrey, 
Kent, Sussex, Southampton, Isle of Wight, Berkshire, Wiltshire, Dorsetshire, 
Devon, Cornwall, and Somerset. 


The proportion of seaside towns in this list is note- 
worthy, and is possibly due to the fact that they are usually 
built hi long strips parallel with the sea, and are thus 
open to absolutely pure air along their greatest length. 

The distribution of infant mortality is then very far 
from uniform, the highest rates occurring in industrial 
towns, the centres of great cities, and mining districts ; 
while low rates are practically universal in rural districts, 
and are met with in many towns of a rural character. 
This distribution emphasises the need of local efforts to 
reduce the evil rather than of measures of general applica- 
tion which take no cognisance of local differences. 

We shall see in the next chapter that the difference 
between urban and rural rates of sickness and mortality 
is not confined to infants, but extends to defects in 
children, and to disease and death in all classes at all 
ages. This is one of the most striking facts brought out 
by a study of vital statistics ; but although recognised in a 
general way, it is doubtful whether the full extent of the 
difference has been realised, and it is certain that nothing 
like sufficient attention has been devoted to ascertaining 
its causes. If we are to reduce infant mortality in this 
country, and improve Public Health in many other direc- 
tions, recognition of the overwhelming effects of urbanisa- 
tion, and investigation of its exact cause, must form the 
basis of all effective action. 

The Possible Causes of Infant Mortality 

It might have been expected that with so important a 
clue furnished by the distribution of infant deaths, some 
unanimity would have existed as to the cause or causes 
of these deaths. But this is not the case ; a great variety 
of causes are brought forward, such as defective sanitation, 
poverty, overcrowding, bad housing, insufficient nutrition 
of the mother, want of breast-feeding, maternal ignorance, 
and paternal vice, and there is little attempt to estimate 
the relative effect of each of these factors. In general 
it will be found that each investigator tends to regard 
as the most potent influence that evil which is most often 


or most strongly brought under his notice. The gynaeco- 
logist, while admitting other causes, dwells most urgently 
upon pre-natal influences, such as syphilis or malnutrition, 
and upon lack of attention at birth ; the educationalist 
upon ignorance ; the temperance reformer upon alcohol- 
ism ; and the worker among women upon the employment 
of women in factories. As an illustration of the extent 
to which views differ regarding the effects of different 
influences, we may note the utterances of some distinguished 
authorities. Dr. Newsholme, of the Local Government 
Board, though he by no means excludes other factors, says 
in the general summary of his report : " Infant mortality 
is the most sensitive index we possess of social welfare and 
of sanitary administration especially under urban condi- 
tions." 1 Sir George Newman, on the other hand, says : 
" It is now a well-established truism to say that the most 
w ' injurious influences affecting the physical condition of 
" young children arise from the habits, customs, and 
" practices of the people themselves rather than from 
" external surroundings or conditions. The environment 
" of the infant is its mother. Its health and physical fitness 
" are dependent primarily upon her health, her capacity 
" in domesticity, and her knowledge of infant care and 
" management." 2 And again : " The principal operating 
" influence is the ignorance of the mother and the remedy is 
" the education of the mother." 3 Dr. Mary Scharlieb, a 
member of the Royal Commission on Venereal Diseases, 
says : " The responsibility for the excessive amount of 
" infant mortality must be distributed, as we have seen, 
" among many causes, but probably the most frequent 
" cause, and certainly the one most within our power both 
" to avoid and cure, is syphilis." 4 

There is no doubt that every one of the causes mentioned 
operates to some extent ; but it is not sufficient merely 
to know this, for some of them probably exert only a very 
minor influence, while others are of great importance. It 
is clear that we must have an idea of the relative effects 
of different causes of infant mortality in order to apply 

1 "Infant and Child Mortality," Supplement to Thirty-ninth Annual Re]iort 
of the Local Government Board, 1910. a Annual Report for 1914. 

3 Annual Report ior 1913. Italics in original. 4 Nineteenth Century, May 191 fi. 


sound remedies, for if we do not possess this, we may be 
led to devote much attention to a factor which is only 
slightly responsible, while neglecting those which produce 
serious effect ; and it will be shown that this is actually 
occurring. The problem of determining and measuring 
the causes of infant mortality is exceedingly complex, and 
in spite of the great amount of work which has been done, 
still demands much further investigation, particularly 
by persons not committed to definite views or holding 
official positions, for these are apt in consequence to seek 
only evidence in support of their views. Nevertheless, the 
lowness of the infant mortality rates in rural districts 
almost without exception should afford a valuable clue 
as to what is the precise cause of the excessive rates in 
urban environments, for it must be remembered that 
many of the factors generally believed to be prejudicial to 
infant life are as prevalent in country districts and villages 
as in towns, and we have therefore considerable justification 
for eliminating those factors which are common to the 
two environments. We will examine seriatim the causes 
most frequently held responsible for high infant mortality. 
Poverty is often looked upon as one of the greatest 
causes of infant deaths. Yet per se it does not appear to 
be so. The wages paid in agricultural districts are notori- 
ously the lowest paid in the community, yet the infant 
mortality rate in rural Wiltshire averages only about 60, 
while in Kensington the average is over 100. The earnings 
of the Connaught peasant or the Highland crofter do not 
approach those of the miners of Durham or Glamorgan- 
shire, yet the loss of infant life among them is only one- 
third of that in mining areas. The influence of poverty 
is felt most directly in housing and food-supply, yet it is 
impossible to say that in these respects rural districts are 
better off than towns. It is well known that housing in 
many rural districts is deplorable. A cottage may look 
picturesque, but its thatched roof and creepers may hide 
defective walls and floors, unsound drainage, low ceilings, 
and ill-ventilated rooms, fully as bad as those in the 
worst quarters of cities. The rooms may be overcrowded, 
and there may be no adequate conveniences for cooking 


or maintaining cleanliness. 1 And not only may the 
cottages be defective, but in many villages there are 
patches of overcrowding which present the worst features 
of town slums. It is indeed well recognised that the 
difficulty of obtaining sufficient housing accommodation 
for labourers has been one of the great obstacles to agri- 
cultural development in recent years. When we examine 
food-supply we find no reason to suppose that the agri- 
cultural worker is better off in this respect than the town 
dweller. We know as a matter of fact that the poor in 
rural districts are often insufficiently fed, and meat for 
the family may be an exceptional luxury. 

Defective Sanitation. — The word ' sanitation ' is here 
used not in its widest sense as meaning all conditions 
making for healthy living, but as applying to the services 
for the supply of water and the removal of household waste 
material, etc. As regards water-supply the services in 
large towns under the control of big companies or muni- 
cipalities are undoubtedly better than those in many 
villages which are dependent upon wells and surface sources 
for their water ; and the same difference applies to house- 
hold sanitary conveniences. In various mining and in- 
dustrial towns in the north of England it is true that the 
ashpit system and insufficiently frequent removal of dust 
and refuse contribute to infant mortality, particularly from 
epidemic diarrhoea, but we cannot regard the difference 
in these respects as sufficiently great or widespread to 
account for the great difference between urban and rural 
infant mortality. In many large towns, especially in the 
south of England and the Midlands, the sanitary services 
are highly efficient and in accord with the most modern 

1 Mrs. Bruce Glasier has given us the following picture of such conditions : — 
" I have myself lived among such women for over twelve years — for six of them 
in a 5s. a week cottage in Derbyshire, and know by first-hand experience as well 
as by intimate friendship what the work of such a home involves. 

" There are no ' modern appliances,' no hot water at the sink, too often hardly a 
decent oven, or a boiler for washing clothes ; lighting is by candle or paraffin 
lamp, and mud will be mud — inches deep — and be brought into the house at all 
hours of the day in wet weather as the children run to and fro. On a small wage, 
in an overcrowded kitchen, to bake the bread and wash the clothes, to prepare 
meals thriftily, to keep the children clean and mended and warmly provided for 
— and not to let that home degenerate into an unkempt hovel or herself and her 
children sink into a condition of grubby animalism, is to be a skilled and heroic 
toiler, sixteen hours a day for seven days a week." — Daily News, February 21, 1916. 


ideas, yet some of these towns show an infant mortality 
rate of over one hundred. In London, municipal sanita- 
tion has attained a high level of excellence, yet wide areas 
in the central parts exhibit an infant death-rate ranging 
from 100 to 140 per thousand births. On the other hand, 
sanitation in many rural districts is still very primitive. 
In the west of Ireland many villages are deplorably insani- 
tary and the habits of the people sometimes most un- 
hygienic, yet these districts exhibit the lowest rates of 
infant mortality to be found in the British Isles. 

Infectious Diseases. — Another factor which might be 
suggested, is the greater probability in towns of infection 
by diseases common among children, such as measles, 
whooping-cough, and diphtheria. To determine this point 
with absolute certainty we require to know the number of 
cases of each disease in urban and rural environments 
respectively, and not merely the deaths ; but since measles 
and whooping-cough are not notifiable diseases, this in- 
formation is unavailable. General experience however 
shows that both diseases are widespread in every type 
of locality ; and wherever there is a school, opportunities 
for transmission exist. Scarlet fever and diphtheria are 
notifiable, and we find that the incidence of these diseases 
does not differ largely in town and country ; notifications 
of scarlet fever, in 1914, having been 474 per thousand of 
the population in the aggregate of County Boroughs of 
England, and 3 45 in the aggregate of Rural Districts ; and 
notifications of diphtheria having been 1'54 and 132 re- 
spectively. Arguing from analogy, we may infer that 
measles and whooping-cough do not differ widely in 
incidence in urban and rural districts ; though, as we 
shall see later, their mortality rates are much higher in 
industrial towns than in rural areas. 

Breast-feeding is undoubtedly an important factor in 
maintaining health in infants, but there is no reason to 
suppose that it is not as widely adopted in towns as in 
the country. Dr. Newsholme has estimated that over 80 
per cent of wage-earning mothers suckle their children. 
Dr. Manby of the Local Government Board, who specially 
investigated this question in Widnes, where infant mor- 


tality is very high, found that breast-feeding among the 
working classes was " almost universal." It may be 
noted that the poorer the home the more likely is the infant 
to be breast-fed, since it is the most economical course, 
and also to some extent because of the widespread belief 
among the uneducated that so long as a mother suckles 
her child she will not again become pregnant. It is 
certain that the proportion of mothers of the wealthier 
classes who suckle their infants does not reach 80 per cent. 1 
Industrial Employment of Women. — This is a factor which 
at first sight might appear to possess much importance, 
since it might conceivably have an injurious effect upon the 
infant while the mother is pregnant, and it is known that 
after birth it tends to hinder breast-feeding. But special 
researches here also have failed to establish a close and con- 
stant connection between women's labour and high infant 
mortality. In Wigan, for example, where only 12 per 
cent of the total married women and widows are engaged 
in non-domestic work, the infant mortality rate in 1913 
was 180, whereas in the textile town of Rochdale with a 
percentage of 28 so employed, the rate was only 106. The 
question is complicated by the fact that among the poorest 
classes harm caused by employment may be more than 
counterbalanced by the additional food and home com- 
forts which the mother is able to purchase with her earn- 
ings ; but, as Dr. Newsholme has pointed out, the industrial 
employment of married women cannot be looked upon 

1 While it is important on many grounds to encourage breast-feeding, there is 
perhaps some danger of exaggerating the harm done by artificial feeding. Statistics 
certainly show that the death-rate among bottle-fed babies is much higher than 
among naturally-fed infants, particularly from diarrhoea, but caution must be 
observed in drawing conclusions from these, for it must be remembered that the 
class of artificially-fed infants includes some who ceased to be breast-fed because 
they were not thriving on that system, and their deaths may be due to some cause 
acting before the artificial feeding was commenced. Experience among the 
wealthier classes shows that if other conditions are satisfactory it is quite possible 
to rear a healthy child on cows' milk. On the other hand, the investigations of 
Dr. Lawson Dick, described on p. 118, show that rickets may be very prevalent 
among children who have been breast-fed. The injurious effect of bottle-feeding 
would appear to be limited to the first year of life. Dr. R. H. Norman, from a study 
of 313 children between the ages of 3 and 8 years in the infant schools of St. Pancras 
and Holborn, found that a larger percentage of children, who had been breast-fed 
during the first year, fell below the average both in height and weight than bottle- 
fed children. He points out, however, that we cannot eliminate other factors as 
being responsible for the difference. ( Annual Report of London County Council on 
Public Health, 1913.) 


as the chief cause of infant mortality. Dr. Greenwood, 
formerly M.O.H. for Blackburn, found very little difference 
in the infant mortality rates among mothers industrially 
employed and those not so occupied, and he says: " As 
a result of this investigation I came to the conclusion that 
no case had been made out for the further restrictive 
legislation in the prohibition of employment of women in 
the cotton mills in Blackburn." x Dr. Jessie Duncan at 
Birmingham found that there was scarcely any difference 
in the weights of children whose mothers were industrially 
employed and those whose mothers were not. We may see 
that hard work is not necessarily incompatible with low 
infant mortality, for women often undertake heavy labour 
about farms, and even toil in the fields, in many parts of 
France and the remoter districts of Scotland and Ireland. 
The unprecedented demand for female labour during the 
war does not seem so far to have caused any rise in the 
infant mortality rate. 

Skilled Attendance in Child-bed. — The value of attend- 
ance by doctor or midwife will be examined in detail in 
the chapter on Medical Treatment among the Working 
Classes. For the present purpose it is sufficient to point 
out that the facilities for such attendance are obviously 
greater in towns than in country districts, in many of which 
the supply of midwives is inadequate and the services of a 
neighbour may be the only help available. In St. Helens, 
Cardiff, Bootle, Walsall, and Stoke-on-Trent, from 80 to 
100 per cent of all births are attended by midwives, yet 
infant mortality in these towns is very high ; 2 on the other 
hand there is no Midwives Act in Ireland, yet the infant 
mortality rate in that country is very low. We shall see 
later that the Midwives Act, which came into force in 1905 
and has been steadily increasing the proportion of trained 
midwives and improving the midwifery service generally, 
has not been accompanied by any reduction in infant 
mortality during the first month of life. 

Ancillary services, such as infant clinics and consultation 
centres, are also few and far between in rural districts. 

1 Jour. Boy. San. Inst., voL.xxxii., 1911. 

3 " Report on Maternal Mortality in Connection with Child-bearing," Supplement 
to Forty-jourth Annual Report of the Local Government Board, 1914-15. 


Maternal Ignorance. — Ignorance of the mother as to 
the proper way in which to feed and care for her child is at 
present widely regarded as one of the chief causes of infant 
mortality. Sir George Newman's views, already quoted, 
meet with much support, and measures for the dispelling 
of maternal ignorance form the basis of the modern cam- 
paign which has led to the Notification of Births Acts, 
the establishment of schools for mothers and classes in 
1 mothercraft ' for girls, and the visiting and advising of 
mothers on the care of infants — looked upon as a very 
important part of a health visitor's duties. For the 
present purpose it would be sufficient to point out that 
facilities for such instruction are more numerous in towns 
than in the country, and if they have an appreciable influ- 
ence, we might expect mortality to be lower in urban than 
rural districts. In view however of the importance now 
attached to maternal ignorance as a cause of infant deaths, 
it is desirable to examine the subject in greater detail. 

That some ignorance exists among mothers is unques- 
tionable, but many facts show that both its extent and 
effects have been grossly exaggerated. If maternal ignor- 
ance is the main cause of a high infant mortality rate, we 
must necessarily conclude that where the rate is low 
mothers are well instructed. But there is no reason to 
believe that rural mothers are so much better informed in 
the care of infants than their town sisters. We cannot 
assume that the Con naught peasantry — many of whom 
can neither read nor write — are so well instructed in the 
care of infants that as a result infant mortality among 
them, in spite of poverty and hard conditions, is one-half 
that among the mothers of Kensington or Westminster, 
and one-third of that in Bradford where so much has been 
done in providing instruction for mothers. If it be ob- 
jected that these areas are too widely separated and diverse 
for fair comparison, then we can examine rates among 
mothers drawn from the same class and brought up and 
educated in essentially the same way, and we must 
believe that mothers living in the peripheral parts of 
London, such as Wandsworth, Stoke Newington, East 
Ham, and Ilford, know far more about the care of infants 


than those in the central parts, such- as Bermondsey, 
Finsbury, and Shoreditch. If instead of areas we examine 
social classes, we find that the wives of woodmen and 
foresters must be credited with as great a knowledge of 
the conditions governing infant welfare as that possessed 
by the professional groups ; and we must believe that the 
wives of agricultural labourers and shepherds excel in this 
respect all other classes of manual workers. 

There is as much lack of the scientific spirit in drawing 
deductions relating to infant mortality as is displayed in 
regard to infectious diseases. If a school for mothers or an 
infant clinic is opened in a district, and infant mortality 
declines, the relation of cause and effect is at once claimed. 
A well-known and earnest social reformer, describing the 
instruction given to mothers at an infant clinic, writes : 
" Special stress is laid on the hygiene of the home, good and 
sufficient food, sufficient and suitable clothing, cleanliness, 
and a proper amount of sleep. The children are examined 
and weighed weekly, so that some idea can be gained as to 
the beneficial results of the advice given." It is evident that 
in the mind of this sincere philanthropist all improvement 
must be ascribed to the advice given ; but it is impossible 
to believe that those who write in this strain really know 
the conditions among large masses of the poor and their 
utter inability to follow the courses indicated. Dr.Wanklyn 
of the London County Council has vigorously described the 
difficulties against which the poor have to struggle, and 
the following is an account he gives of a London tene- 
ment which is typical of many such habitations : — * 

The tenement comprises the two top rooms of a small house, 
without any offices, conveniences, or adjuncts of any kind, except 
a wall cupboard. The front room measures 14 ft. by 11 ft. by 6 ft. 
6 ins., and the back room 9 ft. by 7 ft. by 6 ft. 6 ins. They are in 
fair repair, but some wood-work running round the room is said to 
be infested with bugs. . . . There is no place for storing food or 
crockery or knives and forks and the rest, except one wall cupboard 
in the front room. There is no scullery, no sink, or even water for 
washing up, no draining board or any place on which to handle clean 
things ; no water-closet nearer than at the foot of thirty-six stairs ; 
the w.-c. is in the back-yard and is used in common by thirteen 

1 " Working-class Home Conditions in London," Trans. Eoy. Soc. of Med., 1913. 


people in the house, no one person is responsible for its cleanliness. 
There is no slop sink or a sink of any kind nearer than the w.-c. 
There is a wash-house ; it is in the basement below the level of the 
back- yard ; it is used on separate days by the various inmates of 
the house. The yard may serve as a drying-ground, but it is a long 
way off from the attic. There is no coal or wood store except the 
wall cupboard in the front room. There is no cold water tap nearer 
than in the back-yard or the basement. It was stated that as soon 
as the tenement was occupied water was to be laid on to a tap placed 
half-way between the first and second floors, with a small sink placed 
underneath it. There is a small cooking range but no hot water 
supply. Shortly afterwards there came to live in this tenement a 
man and wife and four children, the six persons permitted by the 
by-laws to occupy its cubic space. 

Dr. Salter has stated recently that there are only 125 
houses or tenements in Bermondsey with a bath-room, 
and of these 96 are in public-houses. These conditions are 
widespread, and they effectually prevent any semblance of 
decent living. Cleanliness cannot be maintained ; privacy 
is impossible ; children cannot sleep properly when there 
are three or more in a bed ; and their growth is stunted 
when their only fresh air is that of the slums, and their only 
playground the streets. When we add to these conditions 
the task of ekeing out a weekly wage to provide food for a 
family, it becomes outrageous to ascribe dirt and neglect 
to maternal ignorance under such circumstances. 

Mrs. Pember Reeves, who has very ably investigated 
housekeeping conditions among the poor, has given us a 
number of family budgets, of which the following is a 
typical one for a week : — 1 
Mr. K., labourer. Wages 24s. 


Burial insurance 

Oil and candles 

Coal . 

Clothing club . 

Soap, soda 

Blacking and blacklead 

Left for food 
A note against the budget says : " Sole old pram for 3s., it was 
too litle. Bourt boots for Siddy for 2s. 11 |d. Made a apeny." 

Jlows wife 22s. 6d. 

Six children. 














9s. 9£ 


1 Round about a Pound a Week, 1913. 


Mrs. Pember Eeeves says : " That the diet of the 
poorer London children is insufficient, unscientific, and 
utterly unsatisfactory is horribly true. But that the real 
cause of this state of things is the ignorance and indiffer- 
ence of their mothers is untrue. What person or body 
of people, however educated and expert, could maintain 
a working man in physical efficiency and rear healthy 
children on the amount of money which is all these mothers 
have to deal with ? It would be an impossible problem if 
set to trained and expert people. How much more an 
impossible problem when set to the saddened, weakened, 
overburdened wives of London labourers ? ' : 

Here is another picture of life among the poor given by 
a special constable i 1 "On Thursday morning I was on 
duty from two to six o'clock — a pouring wet morning — 
and at 3 a.m. I counted no less than fourteen children 
seeking the warmth of the brazier in Cheval Place. There 
were three girls, aged eleven, twelve, and fourteen respec- 
tively, and eleven boys, whose ages varied from nine to 
fourteen. They lay huddled together on the wet flags 
round the brazier in the rain — most of them thus falling 
asleep — a truly pitiable sight ! One wonders what chance 
these children can have of proper physical development." 
These children had taken up their places in order to be the 
first to buy the previous day's bread when the bakeries 
opened at 6 a.m. Further letters showed that this was 
not an exceptional occurrence, but that the practice had 
been established for a considerable time in widely separated 
districts. The children on inquiry were found to come 
from respectable parents, to whom the loss of the bread 
would have been a severe privation, and some of them had 
walked a long way to reach the bakeries. Such are the 
real conditions among the poor in this great country ; and 
under these circumstances the glib statements of some 
social reformers regarding maternal ignorance appear to 
the writer intolerable. 

1 Morning Post, January 13, 1915. 


The Influence of Adverse Pre-Natal Conditions 

This also is regarded as a powerful cause of infant 
mortality, of equal or even greater effect than maternal 
ignorance. The view held is that either disease or mal- 
nutrition or poor physical development in the mother affects 
the infant during the period of gestation, and causes it to 
be either still-born or born in a sickly condition which 
leads to death soon after birth. 

Of definite chronic diseases as distinguished from 
general ill-health, syphilis is the only one which has a 
distinct effect upon the infant and is sufficiently wide- 
spread to influence the statistics, for we may neglect the 
relatively small number of infant deaths due to maternal 
heart-disease, diabetes, etc. Syphilis in either parent is 
apt to affect the offspring, nevertheless we cannot regard 
it as a large cause of infant mortality. The total recorded 
infant mortality from this disease in England and Wales 
in 1914 was 1*5 per thousand births, the total mortality 
from all causes being 104'6. It is known that the statis- 
tics on this point are unreliable, since deaths from syphilis 
are sometimes certified under some other cause ; yet if we 
double or even treble the recorded figure, syphilis still only 
becomes responsible for a small proportion of the total loss 
of life. Dr. Fildes, 1 in an examination of 677 London 
infants by means of the Wassermann test, found only four 
syphilitic, of whom one died and two showed no symptoms. 
The most frequent effect of syphilis is to cause still-birth, 
but we shall see later that even in this direction there are 
reasons for thinking that the effect of the disease has been 

The chief maternal conditions, then, which might be 
expected to have an injurious effect upon the offspring 
are poor development and malnutrition, and we must 
examine the effect of these in the degrees commonly met 
with among the working classes, and not those presented by 
extreme cases. When this is done we shall find that mal- 
nutrition in the mother appears to exert very little influence 

1 " Report to Local Government Board upon the Prevalence of Congenital 
Syphilis among the Newly-born of the East End of London," Reports on Public 
Health and Medical Subjects (New Series, No. 105). 



upon the infant. It is well to be quite clear what is meant 
by this statement. The writer does not suggest that a 
mother who is literally half-starved or seriously mal- 
formed will give birth to children as sound as those of a 
well-nourished and well-developed woman ; but that on 
the average the range of variation in these maternal con- 
ditions from class to class and place to place is not suffi- 
ciently great to produce an appreciable effect upon the 
offspring. Working-class mothers in towns are certainly 
on the average much less healthy and vigorous than those 
in rural districts or those of the wealthier classes, but the 
proportion of town mothers who exhibit extreme degrees 
of defectiveness is after all but small. It would appear 
that Nature provides for the offspring first, and though it is 
difficult to believe that the infants of anaemic and poorly- 
nourished mothers would not be affected, it seems that 
unless the condition is extreme the infants do not suffer. 
"Few things," says Sir George Newman, "are more re- 
" markable in the life of the very poor than the apparent 
" vigour and equipment of their offspring at the time of 
"birth. . . . This does not indicate that the health or 
" environment of the mothers during pregnancy is of no 
" account. For such is not the case. The physique of 
" the mother does unquestionably exert an effect on 
" her offspring, but the tendency of nature is on behalf of 
" her infant. It is well indeed that it is so, and it is this 
" that brings perhaps 70-80 per cent of all new-born 
" infants up to a mean physical standard in spite of ill 
" environment or the poverty of the mother's physique." 1 
To test this point we must compare the infant death- 
rates of favourably and unfavourably situated classes 
during the first few weeks of life before the influence of 
the external environment begins to tell. If defective pre- 
natal conditions are the main cause of infant mortality, we 
should expect the difference in these classes to be greatest 
in the early weeks of life, and to decrease as the child gets 
older and farther from the original injurious influences. 
On the other hand, if the post-natal environment is respon- 
sible, we should expect the difference to increase the longer 

1 Infant Mortality, 1906. 


the children are exposed to it. And this is exactly what 
happens. The point is so important that it must be 
examined in some detail. 

The Chief Medical Officer to the London County Council 
has grouped the Metropolitan Boroughs in order of ' social 
condition,' the standard adopted being the percentage of 
children in each Borough who were scheduled for education 
in the Council schools. Group I., which is the best group, 
contains Boroughs in which less than 82 per cent of the 
children were so scheduled ; in Group V., which is the 
worst, 97 per cent and over of the children were scheduled. 
The following table shows the deaths per thousand births 
in each group at various ages for the year 1913 : — 

Infant Mortality in Kelation to ' Social Condition,' 1913 


Group of Boroughs in order of ' Social Condition.' 






Under 1 week 
2nd week 
3rd „ 
4th „ 









Under 1 month 






0-3 months 
10-12 „ 









0-12 months 






Up to two weeks there is practically no difference in 
the death-rate in any of the groups. After the first fort- 
night the rate begins to rise in each group in comparison 
with I., and exhibits the greatest rise in V. At age 4-6 
months the rate in V. is twice as great as that in I., and 
at 7-9 months it is nearly three times as great. It may 
be of interest to give the figures for the Boroughs which 
had the lowest and highest yearly rates : — 


Infant Mortality in Boroughs with Lowest and Highest Rates 




Woolwich, j 




Under 1 week 
2nd week 
3rd „ 

4th „ 








Under 1 month 







0-3 months 
10-12 „ 














0-12 months 







It will be noticed that while the rates in Hampstead 
and Shoreditch are practically identical during the first 
week, and Shoreditch only shows an excess of about 
25 per cent in the first month, by the time the period 7-9 
months is reached, the rate in Shoreditch is more than four 
times as high as that in Hampstead, and at 10-12 months 
it is more than six times as high. 

Dr. Forbes, the Medical Officer of Health for Brighton, 
has shown that in his district the death-rate under one 
week is 20 '4 in the poorest class, and 20*5 in the well-to- 
do class, whereas the rates for the whole year are 144 and 
67 respectively. He remarks that if his statistics are 
correct, " then the better feeding, the better housing, the 
freeing of the mother from manual work and anxiety 
before the birth of the child have no effect upon the health 
of the child at birth." 1 

Dr. Stevenson, of the Registrar-General's Office, in- 
cluded in his report for 1911 a special investigation into 
the relations between infant mortality and the father's 
occupation. He did not separate the rates in the first 
week, but the following are his results at different 
months : — 

1 Jour. Roy. San. Inst., December 1915. 


Infant Mortality in Social Classes at Different Months 
of 1st Year, 1911 

Social Class. 

Under 1 

Middle and upper class 
Agricultural labourers 
Shopkeepers, dealers. 


Skilled workmen 
Intermediate workmen 
Textile workers . 
Unskilled workmen . 
Miners .... 



2-3 4-6 

Months. Months. 




1 Year. 














These statistics show that the excess of mortality in 
the class consisting mainly of unskilled labourers over 
that of the middle and upper classes was 41 per cent in 
the first month, 92 per cent at 2-3 months, 165 at 7-9 
months, and 183 at 10-12 months. We shall see later 
that even in the first month the excess among miners, 
textile workers, and unskilled labourers must be attributed 
to conditions in the external environment and not to pre- 
natal influences. Commenting on the table, Dr. Stevenson 
says : " These astonishing figures not only show what can 
be done, but clearly point to the plan of campaign, viz. 
an attack upon the causes of mortality in the later months 
of the first year of life." 

We have now compared death-rates at periods during 
the first year in different types of urban areas and in 
different social classes, and we will complete the investiga- 
tion by comparing the rates in urban and rural districts, 
this being the most important comparison of all in view of 
the great difference in the yearly rates between these two 
classes of areas. Unfortunately no recent statistics are 
available showing the rates in the first week, nor can we set 
out the figures for the extremes of conditions represented by 
the County Boroughs of the North and the Rural Districts 
of the South. The Registrar-General however gives the 
rates for the County Boroughs and Rural Districts for 



England and Wales as a whole, and the following are his 
figures for the year 1914 : — 
Infant Mortality in County Boroughs and Rural Districts 

. Under 1 
Area - ! Month. 










] Year. 

County Boroughs i 414 
Rural Districts . j 36-7 






Here again we notice that the difference between 
urban and rural rates is small during the first month, but 
increases steadily as age progresses. Dr. Stevenson says 
of these figures : " The chances of survival seem to differ 
but little at birth in town and in the country, but the 
noxious influences of the former soon come into play, 
and make themselves felt to an increasing extent as the 
first year of life progresses, and to a still greater extent in 
the second and third years when the urban excess generally 
approaches 100 per cent, thereafter gradually declining." 

Rates of mortality do not afford an absolutely complete 
index of healthiness, for in addition we ought to compare 
physical development and the incidence of non-lethal 
defects in different classes. Information on these points 
during the first month of life is scanty, but we may note 
Dr. Kerr-Love's interesting and important observation 
that the children of the poorest mothers in Glasgow weigh 
on an average 7'1 lb. at birth, the average weight of a 
healthy child being 7 lb. 1 

When we see therefore that the infant death-rate in 
the first week of life is almost constant under all circum- 
stances, and that the range of variation in the first month 
is small, but that thereafter differences between favourably 
and unfavourably situated classes become progressively 
greater as the child gets older, we are led irresistibly to 
the conclusion that these differences are almost entirely 
due to the action of the post-natal environment and not 
to the influence of pre-natal conditions. Unexpected 
though the conclusion may have appeared at first, it is 

1 Evidence given before the Royal Commission on Venereal Diseases. 


impossible to interpret the figures otherwise than by the 
view that on the average the children of all classes under 
all circumstances are born equally healthy. This is not to 
deny that in each class and in each type of environment 
a certain number of children die from the pre-natal effects 
of some deficiency or defect in the maternal organisation, 
but we shall see later that this number is remarkably 
constant and appears to have no relation to the external 
environment. The town mother, though on the average 
less well-nourished than her country sister, seems yet to 
have a margin to spare, and Nature takes care that her 
infant does not suffer. If the view that the infants of all 
classes are born equally healthy is correct, it follows that 
as far as physical development is concerned there is little in 
the cry that we are breeding mainly from the ' worst stocks.' 

The Effect of a Smoke- and Dust-polluted 

We have now examined, with one exception, the main 
factors which might be held to account for a high rate of 
infant mortality, and we find that differences neither in 
poverty, bad housing, insufficient feeding, defective sanita- 
tion, disease, industrial occupation of women, nor mal- 
nutrition of mothers can be regarded as adequate to 
explain the excessive and widespread difference between 
urban and rural rates of infant mortality. The factor 
which remains to be examined is that of smoke and dust 
in the atmosphere. Dirtiness of the air appears to be the 
one constant accompaniment of a high infant mortality : 
purity of the atmosphere is the one great advantage which 
the agricultural labourer of Wiltshire, the Connaught 
peasant, and the poverty-stricken crofter of the High- 
lands enjoy over the resident in the town. In the opinion 
of the writer, a smoky and dusty atmosphere as a cause 
of infant mortality far transcends all other influences. 

We have noticed that the highest rates of infant 
mortality always occur in manufacturing towns, and over 
these there hangs throughout the year a pall of smoke 
which has been estimated to cut off 20 per cent of bright 


sunshine, and as much as 40 per cent of the total light. 
The soot emitted from the chimneys is not carried off by the 
wind, but falls rapidly in the immediate neighbourhood. 
This is established by investigations such as that of A. G. 
Kuston, 1 who has shown that the amount of solid material 
deposited in the industrial area of Leeds is 1900 lb. per acre 
per annum, while three miles north-east of the centre of 
the town it is only 90 lb., and five miles from the centre 
it is reduced to 62 lb. per acre. In Greater London the 
annual fall is about 440 tons per square mile ; in Glasgow 
it is 1330 tons, and in Coatbridge, the centre of the 
Scottish iron industry, it reaches the amazing total of 
1939 tons. In such towns, if the sanitary services for the 
removal of refuse are not of the highest efficiency, the 
atmosphere is further polluted by the dust blown up 
from the dirty streets, back-yards, and ash-pits, and con- 
tributes particularly to epidemics of enteritis among 
infants. On the other hand, the purity of the atmosphere 
explains the relatively low rates of infant mortality ex- 
hibited by scattered, open, residential, or seaside towns 
which have few factories. In correlation with these facts 
we shall note the excessive mortality from respiratory 
diseases among infants living in industrial towns. 

The factories however are not alone to blame. In 
large crowded areas the smoke poured out from the 
thousands of domestic chimneys is equally pernicious, 
and it is a remarkable fact that in all large cities the 
infant mortality rate tends to increase steadily as we go 
from the periphery towards the central districts which 
never receive a wind that has not passed over a smoke- 
laden area. This distribution is well illustrated by 
London, but in order to study it we must have before us 
a map of ' greater ' London, since we are not concerned 
with the arbitrary boundary of the London County Council 
area, but with the whole great patch of streets and houses. 
There is an outlying ring all round London in which the 
average infant mortality rate was 74 in 1914, and was as 
low as 48 in Wanstead (66 in 1913, and 47 in 1912), 58 in 
Hornsey, and 61 in Ilford. Inside this is an inner ring 

1 Jour. Roy. San. Inst., 1912. 


where the average rate in 1914 was 97 ; and in the centre 
there is an area consisting of Finsbury, Shoreditch, Bethnal 
Green, City of London, Southwark, Bermondsey, Stepney, 
and Poplar, in which the average was 124, and the highest 
figure 142 in Shoreditch. 1 

These differences may be due in part to the outlying 
and more salubrious districts containing a larger pro- 
portion of the wealthier classes, but it is clear that this 
cannot be a preponderating influence from the fact that 
the rates in such places as Ilford, East Ham, Waltham- 
stow, Leyton, and Wanstead are as low or lower than 
that in Hampstead, and lower than those in Kensington, 
Paddington, and Westminster. We can test this point 
better by reference to the urban area consisting of Paris 
and its extensions beyond the walls, since Paris is a city 
much more uniform in character than London and devoid 
of large slum areas. In 1911 the infant mortality rates 
in the central arrondissements ranged from 128 to 189 ; 
in the outer districts they were from 70 to 110, while out 
at Passy the rate was only 54. When considering the 
distribution of infant mortality in a town, it must be 
borne in mind that the children of the wealthier classes 
are by no means so continuously subjected to the adverse 
influence as those of the poorer classes. Not only are 
there occasional and week-end visits to the country, but 

1 The principal districts forming the outer ring are Ilford, East Ham, Barking, 
Woolwich, Lewisham, Wandsworth, Barnes, Chiswick, Ealing, Willesden, Finchley, 
Hampstead, Hornsey, Stoke Newington, Tottenham, Walthamstow, Leyton, and 

The inner ring consists of West Ham, Greenwich, Deptford, Camberwell, 
Lambeth, Battersea, Fulham, Chelsea, Hammersmith, Kensington, Paddington, 
Marylebone, St. Pancras, Islington, and Hackney. 

There are no marked exceptions in the distribution described, but the rate in 
Barking, 97, is exceptionally high for the outer ring. A most interesting object- 
lesson is afforded by a comparative study of the two adjacent districts of Barking 
and East Ham. Barking contains a number of large works, and its infant mortality 
rate has averaged 105 for the three years 1912-14. East Ham is a clean Borough 
with wide streets and open spaces, and at the time of the writer's visit the only 
smoky chimney was that of the municipal electric generating station from which 
great volumes of black smoke were pouring forth. It is but fair to add, however, 
that the general condition of the streets, every one of which appeared to be lined 
with trees, showed evidence of excellent municipal administration. The average 
infant mortality rate in the Borough for 1912-14 was 70. 

In the inner ring the rate of 64 in Chelsea was exceptionally low, but in 1913 
the rate in this Borough was 90, and for the four years 1908-12, it averaged 99. 
In the central area the rate in the City of London, 103, was lower than those in the 
adjacent districts, but the number of births upon which it was based was only 185. 


a large proportion of the children are taken away from 
town during the hottest month of the year, thus escaping 
a particularly trying period, and increasing their power 
of resisting adverse conditions on their return. It would 
be interesting to know how much infant mortality in the 
West End of London would rise, relatively high though 
it is, if infants and their mothers saw as little of the country 
throughout the year as most of the mothers in Bermondsey 
and Shoreditch. 

In Liverpool, Manchester, and most other large cities 
the same tendency for infant mortality to increase rapidly 
as the central and most crowded parts are approached is 

The Committee for the Investigation of Atmospheric 
Pollution is at present conducting an exceedingly im- 
portant investigation into the purity of the atmosphere 
in various districts, reports on which appear from time to 
time in the Lancet. These results so far show remarkable 
variations in the amount of solid material deposited in 
districts not widely separated. Thus in Birmingham 
Central, the mean monthly deposit amounts to 23 '23 
metric tons per square kilometre, whereas in the south- 
west district it is only 6 '04 ; in Manchester the deposit is 
26 '79 tons at Ancoats Hospital, and only 5 '69 at Bowden ; 
in London the measurement is 19 '47 tons in the Embank- 
ment Gardens, 9 '40 at Wandsworth Common, and 8'44 at 
Ravenscourt Park. As further information accumulates 
the work of the Committee may prove to be one of the most 
important Public Health investigations undertaken in 
recent years. 

Besides the large industrial towns, mining districts 
almost always show high rates of infant mortality, particu- 
larly the colliery districts. If a map showing the incidence 
of infant mortality in England and Wales x be compared 
with a map of the coal-fields, a very marked degree of 
resemblance will be observed. In these districts there is 
not only smoke, but dust to pollute the atmosphere. 
Dr. Fletcher reporting on Chester -le- Street Rural (!) 

1 Such a map will be found in the " Second Report on Infant and Child Mor- 
tality," Supplement to the Forty-second Annual Report of the Local Government 


District has at once drawn a good picture of trie conditions 
and paid a tribute to the miners' wives. He says : — 

As a class, however, and bearing in mind their inferior house- 
accommodation and depressing surroundings of pit-mounds and 
black coal-dusty paths, roads and open spaces about their houses, 
and the general absence of gardens, the miners and their wives deserve 
credit for their indoor cleanliness and tidiness, a condition the main- 
tenance of which involves much labour in dry and windy weather, 
when everything becomes smothered with coal-dust. 

Dwellers in large towns, even in the better parts, are 
largely unconscious of the dirtiness of the air which they 
breathe every minute. The atmosphere may be com- 
pared with a great lake of pure water, and the air in towns 
resembles muddy pools in this lake, with the difference 
that we can see the mud in the pools, but we cannot 
see the dirt in the air. We can see it, however, when 
it has collected in the little masses which are termed 
: ' blacks " so freely scattered over our window-sills. 
Homely illustrations may help appreciation more than 
statistics of deposits. The housewife well knows how 
much more frequently she has to change her white curtains 
in London than in her country cottage ; the city man, 
though he travels first class, and sits in an apparently 
spotless office, can note the difference in his cuffs and 
linen between one day in town and a much longer time 
in the country ; the schoolboy who climbs a tree in a 
London park comes down begrimed, but he may climb 
trees in the Surrey woods and scarcely show any such 
effect. We are continually washing, cleaning, painting, 
and papering the insides of our houses, but we cannot 
touch a balcony rail outside without making our hands 
filthy. This is the air which at every breath we take into 
our lungs, and which is so vital to us that if we are 
deprived of it for a couple of minutes we die. Can we 
wonder that it has a poisonous effect upon the untried 
lungs of the newly-born infant ? 

The rain of solid particles falls upon us continuously 
throughout the year, but is far greater in the winter 
months when more fires are burning ; and it is possible 
that a considerable part of the rise in the general death- 


rate which occurs in winter — the increase being particu- 
larly marked in diseases of the respiratory system — is not 
due to the cold to which we attribute it, but to the greater 
pollution of the atmosphere owing to the larger number 
of fires. Even more marked is the effect of the black fogs 
of large towns, a single week of which causes a rapid rise in 
the death-rate. In this case the moisture has precipitated 
the dirt in the air and largely concentrated it in the lower 
layers of the atmosphere. 

Our knowledge of the physiology of respiration and 
of the pathology of pulmonary diseases is still insufficient 
to enable us to say how a polluted atmosphere exerts its 
deleterious effect. Until quite recent years it was believed 
that the harmful factors in ill- ventilated rooms were excess 
of carbonic acid or diminution of oxygen. Leonard Hill 
has however shoY\'n that this view is no longer tenable, 
and has established that in close, ill-ventilated rooms the 
deleterious factors are excessive heat and moisture in the 
air. 1 But this explanation will not account for the per- 
nicious effect of smoke in the external air, and further 
research is required to determine whether the harm is 
actually due to solid particles or to mineral acids, sulphur- 
ous fumes, or other noxious gases which accompany 
smoke. The effects of breathing air containing dust of 
particular kinds have long been recognised and are signi- 
ficantly described by the terms ' coal miner's lung,' 
' knife-grinder's rot,' and ' stone-mason's phthisis.' Post- 
mortem examinations however show that the lung tissues 
of all persons who live in smoky towns are impregnated 
with sooty particles ; and it is scarcely a stretch of language 
to say that in such an environment every one suffers from 
a modified form of ' coal-miner's lung,' a condition which 
lessens the power to resist bacterial invasion whether the 
bacilli are directly inhaled or enter the body through 
another channel. 

We can actually see the injurious effects of a smoky 
atmosphere in two directions in which we can definitely 
eliminate other factors. The stone-work of buildings 

1 " Report on Ventilation and the Effect of Open Air and Wind on the Re- 
spiratory Metabolism," Reports to the Local Government Board on Public Health 
and Medical Sxibjects (New Series, No. 100). 


becomes extensively corroded in course of time, particu- 
larly that of older buildings erected before architects had 
learnt which stones possess the greatest power of resisting 
atmospheric corrosion. The effect of a smoky atmosphere 
on vegetation is very obvious. Few plants grow as vigor- 
ously in towns as in pure country air, and many will not 
survive at all ; it is said, for instance, that lichens will 
not live within several miles of London, and so far the 
efforts to establish lichens upon the Mappin terraces in the 
Zoological Gardens have failed. There is no question here 
of ' maternal ignorance ' or ' pre-natal influences,' and the 
effect is clearly due to some widespread factor in the air, 
which if so injurious to vegetable life may reasonably be 
supposed to be harmful to animal life. 

In correlation with these facts we may note the im- 
portance attached to the open-air treatment of disease, 
long recognised in the case of phthisis, and now being 
extended to the treatment of children suffering from 
infectious diseases, and, as at Cambridge, of wounded 
soldiers. But if the views of the writer are correct we 
must distinguish sharply between ' pure ' air and ' open ' 
air. We do not provide conditions of health merely by 
inducing slum-dwellers to keep their windows open, or by 
lending, under sanatorium benefit, shelters for consump- 
tives to be erected in the back-gardens of smoky towns. 

The Pathological Causes of Infant Deaths 

We have so far examined the environmental causes of 
infant mortality, but we can also examine the question 
from the totally different standpoint of the pathological 
causes, and we shall find that, using a quite different chain 
of reasoning and quite different sets of statistics, we can 
confirm many of the conclusions reached in the preceding 

If we enumerate all the diseases and conditions from 
which infants die we obtain a fairly long list ; but most of 
these are only of occasional occurrence, and, as a matter 
of fact, by far the larger part of the mortality is brought 



about by quite a small number of diseases which fall into 
the three following sharply-distinguished groups : — 

(1) Respiratory diseases mainly pneumonia and bron- 
chitis, but including deaths from measles and whooping- 
cough, since nearly all fatal cases of these maladies are due 
to the supervention of pneumonia or bronchitis. 

(2) Epidemic diarrhoea and enteritis. 

(3) Developmental diseases and malformations, that 
is, conditions arising from some defect in the child present 
at birth, a group which will be considered in detail sub- 

The following table shows the death-rates from these 
causes in England and Wales, and in the extremes of urban 
and rural conditions, for the year 1914 : — 

Pathological Causes of Infant Deaths, 1914 

Cause of Death. 

Deaths under 1 year per 1000 births. 

and Wales. 

of North. 


of South. 

Total respiratory diseases 


Bronchitis .... 


Measles .... 

Pulmonary phthisis . 

Other respiratory diseases 
Diarrhoea and enteritis 
Developmental conditions 
Other diseases 






All causes .... 




It will be noticed that the excess of infant mortality in 
the County Boroughs over that in the Rural Districts is 
mainly due to the great increase in deaths from two causes, 
viz. respiratory diseases and enteritis. The excess from 
respiratory diseases is 153 per cent, and from diarrhoea 
285 per cent; whereas the excess from developmental 
conditions is only 37 per cent and from other diseases 90 
per cent. The class ' other diseases ' consists mainly of 


non-pulmonary tuberculosis, rickets, convulsions, and so- 
called overlying, and it is probable that a certain number 
of these deaths might equally well have been certified as 
due to respiratory causes. There are reasons for believing, 
for instance, that a large proportion of the deaths attributed 
to overlying are really due to respiratory diseases (v. p. 298) 
and ' convulsions ' is a purely symptomatic term, the 
deaths usually resulting from rickets. In view of the 
possibility discussed on p. 74 that the higher death- 
rates from measles and whooping-cough in the County 
Boroughs of the North are due to greater incidence of these 
diseases owing to increased opportunity for infection, it 
may be noted that in the County Boroughs of the South, 
where probably the opportunities for infection are just as 
great but the atmosphere is distinctly purer, the death- 
rate in 1914 from measles was 107 and from whooping- 
cough 3'39 per 1000 births. 

It is impossible not to correlate the very marked 
excess of infant mortality from respiratory diseases in 
large towns with impurities in the atmosphere. It would 
not be appropriate here to discuss in detail the pathology 
of the process, but it is most probable that the irritation set 
up in the lungs renders them peculiarly liable to attacks 
of micro-organisms. 

Epidemic diarrhoea is a disease the exact etiology of 
which is still obscure. Nevertheless it is definitely estab- 
lished that the disease is most prevalent and fatal in hot 
dusty weather, the incidence always rising rapidly in the 
third quarter of the year in all types of districts, though 
the increase is far greater in the County Boroughs than in 
the Rural Districts. 1 Dr. Newsholme has repeatedly em- 
phasised the injurious effect of dust blown up from dirty 
streets, ash-pits, and privies in towns where scavenging 
is inefficient. It seems probable that the infection is 
conveyed into the system through food, and it is possible 

1 Dr. Ralph Vincent says : " The higher the temperature of the late summer, 
the greater the prevalence of the disease, especially if this high temperature be 
associated with but Uttle rain. In other words, meteorological conditions involving 
a high temperature with much dust are those which promote the conditions which 
accompany the greatest incidence of the disease." — Etiology of Zymotic Enteritis, 



that the value of breast-feeding arises not so much from 
an inherent superiority of human milk as from the fact 
that it affords a pure supply. 

The criticism may be made that the writer has ignored 
climatic differences in comparing the warm and dry south 
with the relatively cold and wet north, and it may be urged 
that this is at least partially responsible for the excess of 
respiratory diseases. To meet this criticism therefore 
the following table has been compiled for the County 
Districts of the northern half of Scotland, where, if cold 
and wet are important factors in producing respiratory 
diseases in infants, the greatest effect should be observed. 
The area dealt with consists of the counties of Orkney, 
Shetland, Caithness, Sutherland, Eoss and Cromarty, 
Nairn, Aberdeen, Elgin, Banff, Inverness, Kincardine, 
Argyll, Perth, and Forfar for the year 1914, the total 
number of births being 11,107. 

Pathological Causes of Infant Deaths in Northern 
Scotland, 1914 

Cause of Death. 

Deaths under 1 year 
per 1000 births. 

Total respiratory diseases . 


Bronchitis .... 


Measles .... 


Pulmonary phthisis . 
Other respiratory diseases 
Diarrhoea and enteritis 


Developmental conditions . 
Other diseases 

j 19-08 

All causes .... 


We have here a record of the pathological causes of 
infant mortality under perhaps the most extreme differ- 
ence of rural conditions as compared with the south of 
England to be found in the British Isles, yet it will be 
noticed that the differences in the death-rates are astonish- 
ingly small. Deaths from pneumonia, bronchitis, and 
diarrhoea are almost identical, and the difference in whoop- 


ing-cough and measles would probably have disappeared 
if the statistics had been calculated over a term of years. 

Deaths from Developmental Conditions 

We must now direct attention to the third great cause 
of infant mortality, viz. developmental conditions, from 
which we can learn lessons of entirely different character 
but of equally great importance. The tables given show 
that the range of variation in the mortality from develop- 
mental conditions does not approach in any degree that 
exhibited by other causes of death, leading to the remark- 
able and apparently paradoxical result that in rural dis- 
tricts, although the mothers are the healthiest, develop- 
mental conditions form by far the largest single cause of 
infant mortality, accounting for more than 40 per cent 
of the total deaths in the first year. In Berkshire and 
Oxfordshire, the two counties in winch the rural infant 
mortality was lowest in 1914, no less than 111 out of a 
total of 243 infant deaths were due to developmental 

The actual range of variation in deaths due exclusively 
to conditions existing at birth is, however, even smaller 
than that shown by the deaths in the table, since the latter 
include a small proportion which are really due to the in- 
fluence of the post-natal environment. In order to bring 
out this fact and demonstrate the remarkable constancy 
under all circumstances in the death-rate from conditions 
present at birth, we must analyse this group more fully. 

The term ' developmental conditions ' is applied to a 
group of diseases or structural deficiencies, well recognised 
by medical men, which consists of the following sub- 
divisions : — 

Premature birth. 
Congenital malformations. 
Atrophy, debility, and marasmus. 
The first two are clearly due to conditions operating 
before birth ; the third is less definite. It is applied to 
conditions of wasting observed in young infants, not 
caused by any definitely recognisable disease. In the first 




month deaths from atrophy, etc. appear almost always to 
be due to some deficiency existing at birth, but in the later 
months it is impossible to distinguish with certainty 
between the influence of the environment and congenital 
influences. In order therefore to eliminate as far as pos- 
sible this element of uncertainty we must measure deaths 
from developmental conditions not by the mortality in the 
whole year, but by that in the first month. The following 
table shows the distribution of deaths from all three causes 
according to months of the first year : — 

Infant Mortality 

from Developmental Conditions 
1000 Births, 1914 

Cause of Death. 

Under 1 



4-6 7-9 

Months. Months. 


1 Year. 

Premature birth 
Congenital mal- 
and marasmus 
















The two influences, pre-natal conditions and post-natal 
environment, really interdigitate to some extent, but the 
above figures show that by drawing the line at the end of 
the first month we obtain a fairly sharp line of division ; 
for in those deaths, even from premature birth and con- 
genital malformations, which occur after the first month 
we cannot positively exclude the effect of the environment ; 
while, on the other hand, we know from the earlier investi- 
gations that the influence of the post-natal environment 
in causing mortality is small during the first month. 

We have now to examine the death-rates from develop- 
mental conditions in the first month under various circum- 
stances. The comparison between urban and rural dis- 
tricts is the most important, but unfortunately statistics 
are not available to enable the rates in the County Boroughs 
of the North and the Rural Districts of the South to be 
compared. The Registrar-General, however, gives the fol- 
lowing figures for London, the County Boroughs, other 
Urban Districts, and Rural Districts for England and 



Wales as a whole. We can introduce into the same table 
another element of variation by including the figures for 
1911 as well as those of 1914. The year 1911 was one 
with a summer heat of almost tropical intensity, and infant 
mortality in England and Wales rose to 130 ; 1914 was a 
comparatively cool year and the rate was only 105. 1 

Deaths from Developmental Conditions under one Month 
per 1000 Births 


Premature Congenital 
Birth. j Malformations. 


Debility, and 



1914. 1911. 1 1914. 



London .... 
County Boroughs . 
Other Urban Districts . 
Rural Districts 
All Urban Districts 









We note in this table the small range of variation in 
the death-rates from developmental conditions, whether 
we compare different types of areas or years of very differ- 
ent meteorological conditions. London has a small advan- 
tage throughout, but this is probably due partly to differ- 
ences in diagnosis. 2 In any case the range of variation 
is of a wholly different order from that presented by the 
total infant mortality in urban and rural areas, or that 
exhibited by the death-rates from pneumonia and diarrhoea. 
In the first month the mortality from these two diseases 
is small everywhere, but is nevertheless 60 per cent higher 
in London and in the County Boroughs than in the Rural 

We have yet another system of classification which 

1 The writer has preferred to take 1914, since it is the most recent year for 
which statistics are available, but the contrast between the two years would have 
been increased by taking 1912, when the infant mortality rate was 95, the lowest 
on record. As a matter of fact the figures for 1912 are practically identical with 
those for 1911 or 1914. 

2 It may be noticed that in London deaths certified as due to syphilis, pneu- 
monia, and atelectasis (a condition of collapse of the lungs occurring shortly after 
birth), though causing in the aggregate only a small mortality in the first month, 
are all higher than in any other part of the country. 



admits of further comparisons, viz. social classes. The 
death-rates from developmental conditions in the first 
month according to social classes were tabulated as part 
of the special investigation undertaken by the Kegistrar- 
General in 1911, and the following are his figures : — 

Deaths from Developmental Conditions under one Month 
per 1000 Births in Social Classes, 1911 

Social Class. 




Debility, and 


Middle and upper class 
Shopkeepers, dealers, etc 
Skilled workmen 
Intermediate workmen 
Unskilled workmen . 
Textile workers 
Agricultural labourers 





Again we notice the small range of variation from class 
to class and the remarkable way in which the figures agree 
with those given in the preceding table. Unskilled work- 
men, textile workers, and miners, who are under the worst 
conditions, show some increase above the upper and 
middle classes as regards death from prematurity and from 
atrophy, but it would be almost impossible to determine 
whether this is due to causes acting on the mother before 
birth, or to adverse factors in the post-natal environment 
killing off: some prematurely-born infants in the first month, 
who would have survived, either permanently or until after 
the first month, if they had received the care and attention 
they are likely to receive in the upper and middle classes. 
Statistics showing the mortality during the first week, 
and still more in the first day, in different social classes 
would materially assist to determine this point. The 
smaller number of premature births in the upper and 
middle classes may also in part be due to some premature 
births being regarded as still-births, for about one- quarter 
of the total deaths in the first month occur during the first 
day, and in those cases where an infant dies very shortly 


after birth, perhaps only having made a few movements 
or convulsive gasps for breath, it is a very fine line which 
divides live-birth from dead-birth. It is a fact of some 
psychological interest that many mothers are less distressed 
at having a miscarriage than at giving birth to an infant 
which dies immediately ; and the slight straining of the law 
to spare the mother's feelings is perhaps more apt to occur 
among a class where births are mainly attended by doctors 
than in a class where they are principally attended by 

The most significant feature of the table is the agree- 
ment of the rates among agricultural labourers with those 
in other classes of manual workers, although, as we have 
seen, they have so great an advantage over other classes 
in all other causes of infant mortality. 

We have now compared deaths from developmental 
conditions during the first month in urban and rural areas ; 
in years of different meteorological conditions; and in dif- 
ferent social classes, and we find a remarkably constant 
death-rate running throughout, which presents the strongest 
possible contrast to other causes of infant deaths. Mor- 
tality from this cause appears to bear almost no relation to 
the external environment of the mother : a very hot year 
does not send it up ; rural conditions do not bring it down ; 
and, even if we assume that the statistical difference 
between the middle and upper classes and miners represents 
a real difference, the effect of the best social circumstances 
over the worst is far smaller than that apparent in other 
causes of infant mortality. To the writer these facts 
seem to lead irresistibly to the conclusion that the great 
bulk of these deaths are due to some obscure internal 
derangement of normal processes in the mother or infant, 
which are either independent of the external environment, 
or are due to some factor or factors in the external environ- 
ment equally common among all classes and in all environ- 
ments. It would appear that the structural or physiologi- 
cal defects leading to these deaths really fall into the same 
category as those minor defects, such as moles, nsevi, 
contracted foreskins, etc., which are exhibited by a certain 
proportion of children, but do not characterise any par- 


ticular class or environment, and do not appear to have 
any recognisable relation to external conditions. We can 
write ofE a small proportion of deaths from premature birth 
in large cities as due to syphilis, but we know that this is 
an inappreciable cause of prematurity in rural districts. 
A few others are due to acute illness or accidents to the 
mother ; but of by far the greatest number of deaths from 
developmental conditions we do not know the cause, and 
we do not know how to prevent this mortality. It would 
conceivably be possible to reduce the death-rate to some 
extent by carefully watching every mother from the begin- 
ning to the end of pregnancy, providing her with a highly 
skilled gynaecologist during confinement, and protecting 
premature infants by means of incubators and other scien- 
tific refinements. But these extreme measures are not 
practicable, and, as we shall see later, all our efforts in this 
direction have not so far had any appreciable effect in 
reducing infant mortality. Nor is it certain that the rear- 
ing of a certain number of congenitally puny and sickly 
infants would be of any benefit to the race, for these deaths 
appear to represent Nature's failures. Just as in every 
packet of seeds there are some that do not germinate, 
and in the young of every flock some which do not 
survive, so it would appear that mankind must inevitably 
lose a certain proportion of his offspring, and with his 
present knowledge he cannot hope to prevent this loss. 
The deaths from developmental conditions in the first month 
appear to range from 25 to 30 per thousand births, and 
this probably represents the real natural death-rate which 
was postulated at the beginning of the chapter. We see 
here natural selection in operation, uncontrolled and unin- 
fluenced by man's efforts, steadily eliminating the unfit ; 
and we realise how utterly shallow is the argument some- 
times brought forward that by preventing infant deaths 
we are in the long run injuring the national physique by 
interfering with natural processes. We cannot save those 
whom Nature has condemned ; we can only prevent 
deaths from our own errors. 

We have still to examine another class of facts bear- 
ing upon this conclusion, particularly the reasons for the 


decline in infant mortality during recent years, and the 
period in the first year at which this decline has occurred. 
It will be convenient, however, to digress for a moment and 
examine the subject of still -births since this is so inti- 
mately connected with maternal conditions. 


Still-births are not registered in this country, and we 
have consequently no reliable statistics regarding them. 
Still-births occurring after the twenty-eighth week of 
pregnancy must now be notified under the Notification of 
Births Acts, but the law is so incompletely observed — 
the proportion of notifications ranging from 77"8 per thou- 
sand births in Blackpool and 56" 1 in Rochdale to 18'3 in 
Liverpool and 16*3 in Southampton — that no reliable 
deductions can be drawn from the returns. 

Knowledge of the causes of still-births is still very 
indefinite. Probably a large number are due to inevitable 
and uncontrollable natural conditions, and some are caused 
by accident, acute illness, excessive fatigue, etc. ; but for 
the present purpose it is only necessary to consider one 
cause, viz. syphilis, since it is practically the only one over 
which the community might exercise some measure of 
control. Syphilis is generally believed to be responsible 
for a very high proportion of still-births. Dr. Newsholme 
in his report for 1913-14 says : "It appears likely that in 
' the practice of midwives the dead births amount to about 
' 3 per cent of all the births attended by them. Dr. Routh, 
' on the basis of a wide series of observations by many 
' authorities over a large field, estimates that abortions at 
' an earlier period of pregnancy are four times the number 
' of dead-births. This would imply a total ante-natal 
' mortality of 150 per thousand births, which is much 
' higher than the total mortality in the first year after 
' birth. From evidence published by the Royal Com- 
' mission on Venereal Diseases, it appears likely that one- 
' half of this ante-natal mortality is ascribable to syphilis." 
It is of course well established that syphilis is an im- 
portant cause of still-births, and there is no doubt that it 


is responsible for a considerably higher pre-natal than 
post-natal mortality. Nevertheless, in the opinion of the 
writer the estimate of the Royal Commission is seriously 
exaggerated. Careful search through the report and 
volumes of evidence issued by the Commission fails to 
yield any scientific data in support of the estimate ; and it 
appears to have been based upon personal impressions 
of witnesses derived mainly from hospital experience in 
large towns, where, as we know, syphilis is most prevalent. 1 
More scientific investigations appear to indicate that the 
proportion of still-births due to syphilis is considerably 
smaller. Dr. Whitridge Williams, for example, has found 
in a study of 705 fetal deaths after the seventh month of 
pregnancy and including the first fortnight after delivery, 
among 10,000 consecutive admissions of women to the 
Johns Hopkins Hospital in Baltimore, that in the white 
women the percentage of these due to syphilis was only 
fourteen. Among negro women the percentage was 
thirty-five. 2 It is significant to note that notwithstand- 
ing the most painstaking investigation no satisfactory 
explanation could be found for 18 per cent of the total 
fetal deaths from all causes. 

Much greater investigation of the causes, number, and 

1 The exact statement made in the report is as follows : — " Of registered still- 
births probably at least half are due to syphilis (Q. 6519, 11,650, 13,040)." 

The author assumes that ' registered ' in this statement means ' notified.' 

The following were the questions and answers to which reference is given in 
support of the statement : — 

6519. Could you give us any idea as to what proportion of these 3 per cent 
would be due to syphilis ? — (Sir Thomas Barlow) This is only an impression, but 
my impression is that the vast majority of them are. 

11,650. So that a very large percentage of still-births, nearly half we might 
say, is due to syphilis ? — (Dr. Florence Willey) Yes. 

[Dr. Willey had submitted statistics showing that among 77 still-births 
occurring in five years in the outdoor practice of the Royal Free Hospital, 
24, or 31 "2 per cent, were considered to be due to syphilis. In the majority of 
these cases the diagnosis had been based on clinical evidence only.] 

13,040. Would you agree that it is 50 per cent as has been suggested here by a 
witness ? — (Miss Frances Ivens, M.S.) Yes, I should think quite that. 

[In a previous question Miss Ivens stated that she had no statistics.] 

It will be noticed that three impressions by persons, each of whom is attached 
to a hospital in a large town, is the foundation for the sweeping statement in the 
report. The next stage in the creation of a belief is the issue of circulars and 
leaflets by philanthropic societies in which the word ' probably ' and references 
to evidence are dropped ; and finally it becomes an established canon that more 
than one-half of all still-births whether notified or not, are due to syphilis. 

2 " The Limitations and Possibilities of Pre-Natal Care," Jour. Amer. Med. Ass., 
January 9, 1915. 



distribution of still-births is required before we can speak 
with any degree of certainty as to the future. We may 
be able to reduce fetal deaths from syphilis, but to the 
author the outlook for reducing still-births from other 
causes is not very promising. 

The Decline in Infant Mortality in Recent Years 

To return to infant mortality. The conclusions we 
have come to are : (1) that the preventable deaths of in- 
fants are those due to conditions in the post-natal environ- 
ment, mainly smoke and dust in the atmosphere, giving 
rise to respiratory diseases and enteritis ; and (2) that 
the mortality from developmental conditions, which is 
almost restricted to the first month, is practically beyond 
control. If these conclusions are correct, then efforts 
specially directed towards conditions prevailing before 
birth and in the first few weeks of life are futile and wasted. 
The greater part of our efforts to reduce infant mortality, 
such as the Midwives Act, the Notification of Births Acts, 
pre-natal clinics, schools for mothers, and infant consulta- 
tion centres, are of this character, and it will be — as it 
often has been — claimed that the fall in infant mortality 
has proved the value of these measures. This point there- 
fore demands very careful investigation. 

The following table shows the movements in infant 
mortality since 1880 in England and Wales : — 

Infant Mortality in England and Wales, 1881-1915 

Deaths under 

Deaths under 


1 Year per 


1 Year per 

1000 Births. 

1000 Births. 








































It will be seen that there has been by no means a 
constant downward trend. The rate for the period 1891 
to 1901 was for some unknown reason high as compared 
with the rate in 1881-85. Thereafter the fall has 
occurred mainly in two periods. There was an abrupt 
decline in 1902, and then, with some rise in 1904, the rate 
remained constant until 1906. Two years of intermediate 
mortality are followed by another abrupt fall in 1909, and 
again with an exceptional rise in 1911, and an exceptional 
fall in 1912, the rate has remained nearly constant to the 
present year. 

It is impossible to correlate those movements with 
legislative and administrative measures. The Midwives 
Act was passed in 1902, but did not come into force 
until 1905 ; and it did not produce any abrupt change as 
it took in all midwives then in bona fide practice, and it is 
estimated that even in 1913 more than 50 per cent of 
practising midwives were untrained women who came in 
at the beginning. 1 The Notification of Births Act, which 
is the foundation of modern methods, was passed m 
August 1907, but it was then an adoptive Act, and several 
years elapsed before it was at all widely adopted by Local 
Authorities. Even by the end of 1913 the Act was not 
in force in 13 County Boroughs, 159 Municipal Boroughs, 
and 1230 Urban and Rural Districts with a total population 
of nearly 15 millions. The Act cannot be held to account 
for the abrupt fall in 1909, for if its very partial adoption 
during the first two years produced so great an effect, why 
has not this effect continually increased in subsequent 
years with the steadily increasing extension of the Act ? 
The growth of schools for mothers, infant clinics, ante- 
natal clinics, and visiting by health visitors has occurred 
almost entirely since 1910, and has increased with each 
year, but the effect on the infant mortality rate seems to 
have been nil. 

It is perhaps fairer to test the value of these methods, 
not by reference to the infant mortality rate for the whole 
country, but by the rate in a district where they have been 

1 " Report on Maternal Mortality in connection with Child-Bearing," Supple- 
ment to Forty-fourth Annual Report of Local Government Board. 



most zealously applied. Bradford affords a good instance 
for this purpose. The city was one of the first to adopt 
the Notification of Births Act, and it has earned a high 
reputation for the energy it has shown in providing for 
the care of infant and maternal life. It possesses an ante- 
natal clinic and maternity hospital, an infant clinic with 
hospital attached, a system of supplying nursing and 
expectant mothers with food in order to encourage breast- 
feeding, a municipal milk depot, and a staff of health 
visitors, who are in touch with all the departments of the 
child welfare scheme. We have here a picture of municipal 
concern for the Public Health which affords one instance 
in reply to those who assert that Local Authorities are 
"' neglectful ' ; and if these efforts are largely wasted and 
futile, it is not for want of local enterprise and energy, but 
for lack of an independent, central, investigating authority, 
whose business it should be to determine the real factors 
influencing Public Health, afford sound guidance to Local 
Authorities, and prevent the dissemination of erroneous 

For what has been the infant mortality record of 
Bradford ? We will examine the rates for the same years 
as in the previous table. 

Infant Mortality in Bradford, 1881-1915 

1 Deaths under 

Deaths under 


1 Year per 


1 Year per 

1000 Births. 

1000 Births. 








































Comparison with the previous table shows that infant 
mortality in Bradford has varied almost exactly as it has 
in England and Wales as a whole. There was a high rate 



from 1891 to 1901 ; an abrupt fall in 1902, which continued 
to 1906, except for a rise in 1904 ; and a further abrupt 
fall in 1909, which has continued to 1915, broken by the 
rise in 1911 and the fall in 1912. It is obvious that these 
variations have not been due to local efforts but to changes 
in conditions which have prevailed more or less all over 
England and Wales. When we recall that there are 
reasons for thinking that a natural death-rate need not 
exceed 30 per thousand, and that wide areas in all parts 
of the country exhibit a rate which does not exceed 60 
per thousand, it is clear that even if we ascribe the whole 
decline to the efforts made, these efforts are merely touch- 
ing the fringe of the problem. 

We will complete this investigation by showing at what 
periods in the first year infant mortality has declined. 
Unfortunately the Kegistrar-General did not tabulate 
deaths in the first month previous to 1905, though we can 
get earlier statistics for the first three months together. 
The following table shows the information available for 
England and Wales : — 

Infant Mortality in Periods op First Year, 1898-1914 


Under 1 


Total under 





3 Months. 





























































































It will be seen that during the first month the death-rate 
has been almost constant for ten years. In the second and 
third months it has fallen about 20 per cent comparing 
1905 with 1914. In the fourth, fifth, and sixth months 
it has fallen 24 per cent in the same period, and nearly 
50 per cent if we go back to 1898. In the period including 
the seventh to the twelfth month the rate has fallen 24 
per cent comparing 1905 and 1914, and again nearly 50 
per cent as compared with 1898. It is not necessary to 
set out similar tables for Urban and Rural Districts, since 
they present exactly the same characters, the average rate 
in the first month in the County Boroughs of England and 
Wales during the four years 1911-14 having been 42'0 ; 
while in the Rural Districts, in the same period, it was 38 0, 
again showing how limited is the special effect of an urban 
environment during the first month. Infant mortality 
has declined appreciably during the last ten years ; there 
has been some fall during the second and third months 
of the first year, but by far the larger part of the decline 
has occurred during the last nine months of the first year. 
There is no reason to correlate this decline with efforts 
specially concerned with conditions during the first few 
weeks, the death-rate from which has scarcely varied. 
On the other hand, as we shall see in the next chapter, 
the fall has been part of a larger general decline in the 
death-rate, which has been particularly marked during 
the earlier years of life. We shall see that the death-rate 
during the second year has fallen 40 per cent since 1895, 
and that during the third, fourth, and fifth years the fall 
has been even greater, though no special efforts have been 
made to protect life at these ages. There seems every 
reason to believe that the circumstances — natural or 
social — which have led to the decline in one case have 
also brought it about in the other. 

The fact appears to be that under the term ' infant 
mortality ' we are classing together two radically different 
types of deaths, which are brought about by different 
causes and governed by different influences. The first 
type consists of deaths due to developmental factors which 
vary but little from place to place, year to year, and class 


to class ; and are caused by fundamental influences which 
we do not fully understand and apparently cannot pre- 
vent. The second type consists of deaths, mainly due 
to respiratory diseases and enteritis, caused by influences 
in the post-natal environment, most prevalent in crowded 
mining and industrial districts, and probably entirely 

These two types of deaths overlap somewhat in time, 
but the end of the first month gives us a fairly sharp line 
of division. Some 75 per cent of all deaths before that 
line are due to developmental conditions, though the pro- 
portion among miners, textile workers, and unskilled 
labourers is rather less ; on the other side of the line the 
proportion of deaths due to developmental conditions is 
small. Broadly speaking, mortality in the first month is 
a special thing which has hitherto baffled us and may con- 
tinue to do so indefinitely ; mortality after that age is 
part and parcel of the general mortality, due to the same 
causes and demanding for its reduction the same measures. 
For various statistical purposes we must no doubt continue 
to tabulate deaths according to years of age ; but in future 
analyses relating to deaths of infants we should do well 
to drop altogether the misleading term ' infant mortality,' 
and call mortality in the first month by some such term 
as ' developmental ' or ' birth ' mortality, and mortality 
from the end of the first month to the end of, say, the 
third year as ' mortality of early childhood.' We are at 
present forcing an arbitrary and artificial classification 
upon a series of phenomena which fall naturally into quite 
different classes, and by adopting some such scheme as 
that suggested we should classify these deaths approxi- 
mately according to the lines which Nature herself has 
laid down. Further, we should have a better means of 
estimating the effect of any particular step, and we should 
have brought home to us the fact that measures specially 
directed towards saving life among infants are of very 
little value, while those which will benefit all children, 
and indeed all classes of the community, are also those 
which will reduce mortality in the first year of life. 

One final point remains to be considered, and that is 


the reason why mortality during the later part of the 
first year has declined. To ascertain this a prolonged and 
laborious investigation would be necessary, applying not 
only to the first year, but to the second and third years. 
Probably a number of factors, such as better social con- 
ditions and prosperity, improved general sanitation, im- 
proved methods of medical and surgical treatment, in- 
creased institutional treatment, and natural decline in the 
virulence of certain diseases, have combined to reduce the 
mortality. The widespread substitution of electric and 
incandescent gas lighting for the gas flame in street, 
workshop, and house may have had an appreciable effect 
in improving the condition of the atmosphere, and possibly 
explains why black fogs have been less frequent in London 
in recent years. 1 It would be impossible to allocate to 
each influence its exact share in the final result, but we 
may notice the important effect of meteorological con- 
ditions upon the death-rate in infants. We have seen 
that variations in climate between different parts of the 
British Isles in the same year have very little influence, 
nevertheless widespread changes over the whole country 
from year to year have considerable effect. A chart of 
the infant mortality in England, Scotland, and Ireland 
shows that for many years the tracings have risen and 
fallen with a high degree of parallelism, indicating that 
some influence common to the three countries has year 
by year affected the rates, and this can only be meteoro- 
logical variations. 2 We may note this influence on an 
even larger scale, for the very hot year 1911 was one of 
high infant mortality in most European countries, while, 
on the other hand, 1912 saw the lowest rates on record 
established in Austria, Belgium, Denmark, Finland, France, 
Germany, Holland, Hungary, Italy, Switzerland, and the 
United Kingdom. No greater contrast exists than in the 

1 Many housewives who used the old ' bat's-wing ' burner will recall that no 
sooner was a ceiling whitewashed than a grey patch again began to appear above 
the gas jet, and in a few months the condition of the ceiling was worse than it 
becomes now after as many years of electric lighting. It is probable that from 
this change alone the modern nursery of the wealthier classes is much more 
hygienic than was the nursery of twenty years ago. 

2 The Report of the Registrar-General for Ireland for 1914 contains such a 
chart beginning with the year 1861. 


rates provided by these two consecutive years, and in 
every country for which later figures are available the 
rates have risen in succeeding years. We may note that 
during recent years we have had a remarkable series of 
mild winters and cool wet summers, broken only by 1911, 
and it is possible that these conditions have had an im- 
portant influence in reducing the infant mortality rate. 

The Need for Further Eesearch 

Whether the views put forward in the preceding para- 
graphs are correct or not, it is clear that there is still a 
vast field for research into infant mortality ; and it is 
equally clear that we have adopted a number of expedients 
without any adequate investigation of the effects they 
might be anticipated to produce, or examination of their 
value after they have been in force. We have here the 
first instance of the way in which futile efforts are made 
and money wasted to the detriment of Public Health, 
owing to the lack of a central, independent, investigating 
authority, specifically charged with the duty of studying 
all questions relating to Public Health, a function which 
could only be discharged by a Ministry of Health possessing 
power to prescribe returns and reports. Statistical in- 
vestigations such as those in the previous pages are exceed- 
ingly laborious ; there is little pecuniary reward attached 
to the work ; and it is rarely possible for a private 
individual to devote to them the time they demand. 
An immense amount of material for research is already 
in existence, but is scattered through the reports, 
statistics, and returns of all countries. If the views 
expressed are correct, then we should expect to find 
infant mortality in France, Germany, America, and our 
Colonies exhibiting essentially the same characteristics, 
the same difference between town and country, and the 
same constancy in developmental defects, etc. ; and 
where differences occurred, new light would be thrown 
upon the subject by ascertaining the causes of these 
differences. But to examine the vast series of blue-books, 
reports, and scientific papers is the work, not of one 


man, but of a staff. In this country what is most 
required is a detailed study of a rural district. We have 
had numerous investigations into infant mortality in large 
towns, but no one appears yet to have thought it worth 
while to make an exact study of rural mortality. If we 
knew the precise causes and circumstances attending, say, 
even one hundred consecutive deaths under one month 
in a rural district, we should have some indication whether 
congenital and unpreventable influences do actually play 
the large part suggested. 

The constitution and functions of a Ministry of Health 
will be discussed in detail in a subsequent chapter, but we 
may here anticipate this to the extent of urging that the 
great function of such a Ministry should be to undertake 
research into all questions of Public Health, scientific and 
sociological, but particularly the latter since this field is 
not, and cannot be, covered by the present Research 
Committee. Further, this research must be in the hands 
of those who are unfettered in their judgment and un- 
connected with administration. At present each Depart- 
ment responsible for the administration of a Public Health 
measure conducts its own investigations, and in its annual 
report acts as its own judge, with the result that we too 
often get views which are biassed and prejudiced. The 
Registrar-General is the only authority who is entirely 
independent of administration, and he and his staff are 
doing by far the most important Public Health research 
undertaken in this country. Of all the Government 
Departments, they alone have indicated the right course 
to adopt in attacking infant mortality. We have many 
' experts ' but few ' scientific men.' We may leave adminis- 
tration in the hands of experts, but if we are to avoid 
great mistakes, useless expenditure, and propagation of 
erroneous views, we must trust science only in the investi- 
gation of Public Health problems. 



Children below the school age — Physical and mental defects in school 
children — Defectiveness in urban and rural children — Employment 
of children out of school hours — Children in special schools and in- 
stitutions — The folly of palliative methods — Sickness in adults- — Urban 
and rural sickness rates — Defects in army recruits — The principal 
causes of mortality : tuberculosis ; pneumonia and other respiratory 
diseases ; heart-disease ; cancer ; diarrhoea and enteritis ; syphilis. 

We can best study disease and mortality in children 
and adults by considering separately : — children below the 
school age, children at the school age, army recruits, and 
the extent and distribution of the diseases causing the 
greatest mortality and sickness. 

Children below the School Age 

Following the principle adopted in the previous chapter, 
we will endeavour to ascertain what unnecessary loss of 
life is occurring among young children, and where is found 
the highest mortality, by comparing the death-rates in 
different types of area in different parts of the country. 

Mortality in Early Childhood, 1914 


Age 2 years. 

Age 3-5 years. 

England and Wales . 

County Boroughs of North 

„ ,, Midlands 
„ „ South 

Rural Districts of North 

„ ,, Midlands . 
„ „ South 





The preceding table shows the death-rate for the second 
year of life, and for the age three to five years inclusive 
(mean annual mortality), in terms of a thousand living at 
each age. 

It will be seen that the distribution of these deaths fol- 
lows exactly that found for infant mortality, and again we 
notice the overwhelming effect of urbanisation. In the 
County Boroughs of the North the death-rate in the second 
year is nearly five times as high as that in the Rural Dis- 
tricts of the South ; and for the age 3-5 years it is more 
than three times as high. Out of every 10,000 children 
born in the County Boroughs of the North, 2113 are dead 
by the end of the fifth year ; whereas out of the same 
number born in the Rural Districts of the South only 870 
die in the first five years. The County Boroughs of the 
South are much more favourable to child life, but it must 
be remembered that these include many open country 
towns and sea-coast towns. In noting the relatively high 
rates in the Rural Districts of the North we must again 
recall the fact that the word ' rural ' in its ordinary mean- 
ing is an incorrect description of many of these districts. 

In Connaught the death-rate in the second year per 
thousand living at that age was 122 ; in Belfast Comity 
Borough it was 54*7. The Registrar-General for Scotland 
does not tabulate separately deaths in the second year, 
an instance of the defectiveness of the Scottish vital 
statistics, to which further reference will be made. 

The total deaths in the second year of life in England 
and "Wales in 1914 were 24,967. Had the death-rate been 
that prevailing in the Rural Districts of the South, more 
than 16,000 of these deaths would not have occurred. 
At the age of 3-5 years the total deaths were 21,039, and 
of these at least 9085 were presumably avoidable. These 
losses must be added to the 50 per cent at least of infant 
deaths which are due to conditions in the environment, and 
must be regarded as preventable. 

We must now examine the chief pathological causes 
of this mortality. Those responsible for a mortality ex- 
ceeding '7 per thousand are as follows : — 



Causes op Death in Second Year per 1000 Living, 1914 


Total respiratory diseases 


Bronchitis . 



Pul. phthisis 

Other respiratory diseases 
Diarrhoea and enteritis 
Rickets and convulsions 
Diphtheria .... 
Violence .... 
Other diseases 

and Wales. 



of North. 


Districts of 

























All causes 




* In these subdivisions of the country, the Registrar-General's tables do not 
separate rickets and convulsions from ' other diseases.' 

Again we notice that respiratory diseases in some form 
or other constitute the largest cause of death, accounting 
for more than half the total mortality. Diarrhoea and 
enteritis come next. In both cases the mortality is re- 
duced to a remarkable extent in the rural districts. It 
is clear therefore that mortality in the second year 
resembles closely that in the first year after the first 
month, both in distribution and causation, and is governed 
by the same influences. 

In the period from the third to the fifth year the propor- 
tion of deaths due to other causes increases, but the urban 
excess of deaths from respiratory diseases and enteritis 
is even more marked, as shown in the following table : — 

Causes of Death at Age 3-5 years, 1914 

„. County Boroughs 
Dlsease - of North. 

Rural Districts 
of South. 

Respiratory diseases 
Diarrhoea and enteritis . 
Other causes .... 







All causes .... 




Thus while respiratory diseases are six times and 
diarrhoea seven times as high in the County Boroughs as 
in the Rural Districts, the mortality from all other causes 
is only slightly more than doubled. It may be noted 
that neither this nor the preceding table give a complete 
separation of all deaths in which respiratory conditions 
played a part, for ' other causes ' includes deaths from 
scarlet fever, diphtheria, rickets, and other conditions 
the most frequent complications of which, as shown 
by the Registrar-General's secondary classification, are 
bronchitis and pneumonia. 

We may note further that, as with deaths in the last 
three-quarters of the first year, there has been in recent 
years a substantial decline in the mortality in each year 
from the second to the fifth. In the second year for 
example the death-rate in 1881-85 was 531 per thousand, 
while in 1914 it was only 32*8 per thousand. This decline 
has occurred without any special efforts having been made 
to protect the health of children under the school age, for 
such children only share to a very limited extent the advan- 
tages of the recently established infant clinics, etc., and they 
do not come under the school medical service. If we had 
established a medical service of any kind for these children, 
or taken other special measures, it is highly probable that 
the fall in their death-rate would have been claimed as a 
result of these measures. We do not know the reasons 
for the fall nor the diseases in which it has mainly occurred, 
and to determine these would be an exceedingly laborious 
task, though one that might fitly and with advantage be 
undertaken by a Ministry of Health. Probably various 
causes, enumerated in the preceding chapter, have com- 
bined to produce the final result. 

Sickness and Defects in Children below the 
School Age 

Mortality statistics do not tell the full tale of ill-health 
among children, for there are some diseases which, while 
not causing a heavy mortality, are nevertheless responsible 
for much sickness and permanent injury to health and 
growth. The most important of these affections is rickets, 



a disease which is a frequent cause of convulsions in young 
children, and brings about a softening of the bones, often 
leading to permanent curvature of the spine, malformation 
of the chest, ' knock-knee,' ' bandy leg,' and other deform- 
ities. A large proportion of the defects for which recruits 
are refused admission to the army can be traced to rickets 
during infancy. We do not know the exact cause of 
rickets, but deprivation of fresh air, exercise, and sun- 
light, appear to be the largest factors in producing the 
disease. Defective feeding is perhaps only a subsidiary 
influence. The disease is very widespread in large cities. 
Sir William Osier estimates that from 50 to 80 per cent 
of all the children treated at the hospital clinics in London 
exhibit signs of rickets. Dr. Lawson Dick, when examining 
the teeth of 1000 Jewish children atteodingthe L.C.C. schools 
in the East End of London, found that 80 per cent of them 
showed distinct evidence of rickets, and he considers that 
this disease is an important cause of defectiveness of the 
teeth. 1 It is of interest to note that over 80 per cent of these 
children had been breast-fed for twelve to eighteen months. 
Of other defects in young children we have little 
statistical knowledge, since no public authority examines 
these children and records their condition. The West- 
minster Health Society has however made some valuable 
observations, and if the children examined represent a fair 
sample of the poorer population, as there is every reason to 
believe they do, the observations reveal a terrible state of 
affairs. The following table is taken from the report of 
the Society for 1913:— 

Defects in Young Children 

Age of child 

to 1 

1 to 2 

2 to 3 

3 to 4 

4 to 5 

Numbers examined . 


119 120 



Decayed teeth . 
Enlarged tonsils 
Adenoids .... 
Rickets .... 

1 Defects per cent. 

















1 " The Teeth in Rickets," Proc. Roy. Soc of Med., 1916. 


A lamentable fact shown in this table is the steady 
increase in the number of physical defects at each year 
of age, so that by the time the fifth year is reached more 
than half the children have at least one physical defect 
and many have several. From the point of view of health, 
childhood is probably the most important period in life. 
If during early years a child is well fed, well cared for, and 
surrounded by a good environment, vigorous growth will 
be ensured, and a foundation of health laid which will 
enable it much better to resist adverse conditions in later 
years. Children living in large cities are however sub- 
jected to harmful influences from the time they are born, 
with the result that when they come under the school 
medical officer at the age of five, a large proportion of 
them are already badly nourished, stunted in growth, and 
suffering from various defects. The State in its wisdom 
then begins a half-hearted attempt to correct the evil 
wrought, and cure defects which need never have arisen 
if the children had had a better environment in earlier 

Children of School Age 

The death-rate among school children is low. The 
adverse conditions of early years have by this time nearly 
completed their work in killing; and their effect on the 
survivors before and during the years of school life is to 
be measured by malnutrition, poorness of physique, and 

We have now a great mass of information relating to 
the health of school children as a result of the system 
of medical inspection which was established under the 
Education Act of 1907, and this must be examined first. 
But let us note that ' school children ' and ' children of the 
school age ' are not the same ; the former are to an appre- 
ciable extent a picked class, from which the children who 
are too ill or too defective to attend school have been 
separated, and placed in asylums, hospitals, sanatoria, and 
other special institutions, or simply kept at home. More- 
over, the statistics relating to school children deal almost 
entirely with physical defects, and we have no measure 


whatever of the sickness and disease which keeps children 
temporarily away from school. We cannot attempt to 
measure the sickness caused by measles and whooping- 
cough, though we know that the cases of scarlet fever and 
diphtheria, which are notifiable diseases, amount to many 
thousands annually. 

The total number of children who were medically 
inspected in England and Wales in 1913-14 was 1,900,000 
(of whom 1,395,133 were entrants or leavers), and the 
total number of those who were found to be suffering 
from defects or diseases needing medical treatment was 

The Board of Education has not yet found it possible 
to compile a table showing the prevalence of defects among 
the total school population in England and Wales, which 
amounts to some 5,381,500; but the figures in the preced- 
ing paragraph will enable some estimate of this number 
to be made. The point we have to consider is whether we 
can justly infer that the proportion of defects in children 
who were not examined is as high as in those who were 
examined. A child is not medically examined every year, 
and it might be supposed that health is better in the years 
succeeding examination as a result of that examination. 
The present regulations require the medical inspection of 
all children in the year they enter school, all children who 
are between the ages of 8 and 9 years, and all between 
12 and 13 years, together with those over 13 who have not 
already been examined after the age of 12. One of the 
great advantages which was promised from the system of 
school medical inspection was " the early detection of 
unsuspected defects and the checking of incipient maladies 
at their onset," but it will be noticed that two periods of 
two years each pass without any medical examination of 
the child unless for some reason a special exception is 
made ; and if the one examination was at the beginning 
of the year and the next at the end of the year nearly four 
years might elapse between the two examinations. During 
these periods new defects will arise and pass unnoticed 
unless particularly severe, when the child may have 
a special examination. Again, detection of a defect by 


no means necessarily involves its cure or even an attempt 
at its cure ; for we shall see that only about half the 
children referred for medical treatment are actually 
treated, and of these only some four-sevenths are described 
as ' remedied,' and about two-sevenths as ' improved.' 
For these reasons it may be assumed that the health of 
school children during the intervening years is not appre- 
ciably better than that during the year of examination ; 
and this view is confirmed by the statistical returns, which 
show that the proportion of defects found at each succeed- 
ing examination is just as high as that at the preceding 
examination, though no doubt different children figure to a 
considerable extent in the returns. 

Balancing one consideration against another therefore, 
it may be assumed on the basis of the defects found in 
the 1,900,000 school children who were examined in 1913- 
1914, that the total number of defective children in the 
elementary schools of England and Wales is at least a 
million and a half, and this is exclusive of physically and 
mentally defective children in special schools. 1 

The Nature of Defects in School Children 

The chief defects found in school children are mal- 
nutrition and poor physical development, dental caries, 
uncleanliness (i.e. presence of vermin or nits), defective 
vision, diseases of the nose, throat, or ears, affections of 
the heart and circulation, and diseases of the lungs. It 
may be useful to examine these in detail. 

Malnutrition is probably the main cause of stunted 
growth in height and weight, and of deficient chest measure- 
ment — conditions which increase liability to definite dis- 
eases. It is not possible to measure malnutrition exactly 
by figures, since no definite criteria can be laid down, and 
the judgments and standards of medical officers are bound 
to vary within wide limits ; but when all allowance is made 

1 In his report for 1915-16, Sir George Newman says : " Not less than a quarter 
of a million children of school age are seriously crippled, invalided or disabled ; 
not less than a million children of school age are so physically or mentally defective 
or diseased as to be unable to derive reasonable benefit from the education which 
the State provides." 


for this source of uncertainty, it is clear that defective 
nutrition is widespread among school children, particu- 
larly in large cities ; and there is no doubt that in many 
poor districts it actually increases during school life. In 
London, in 1913, 10'8 per cent of the entrant boys and 
9" 8 per cent of the entrant girls showed poor and bad nutri- 
tion ; while among leavers, 14' 7 per cent of the boys and 
14" 3 of the girls showed the same condition. Sir George 
Newman, the Chief Medical Officer of the Board of Educa- 
tion, says in his report for 1913 : "Making allowance for 
" differences of standard among the numerous school 
" medical inspectors, it is impossible to doubt the general 
" result of their findings, that taking London as a whole, 
" there is evidence that the school child undergoes some 
" amount of physical deterioration as regards nutritional 
" condition during school life." It appears therefore that 
so far all our efforts in the direction of providing medical 
treatment and meals for necessitous children have not 
been sufficient even to maintain the relatively low standard 
exhibited at the beginning of school life. In some of the 
industrial towns of the North, and in the worst quarters of 
large cities, the percentages very much exceed those given 
above. In Bethnal Green, in 1913, the nutrition of 51*9 
per cent of the boys and 40*7 of the girls was described 
as ' poor ' or ' bad.' In country districts the proportion 
is much smaller than in large towns. 

We do not know the precise reason why so many city 
children exhibit malnutrition or defective growth. It is 
not entirely a question of insufficient or improper feeding 
— possibly not even mainly — for the condition may be 
displayed by a child who has always been well fed. Im- 
portant contributory factors are rickets in earlier years, 
overcrowding, pollution of the air, want of exercise and 
proper playing-fields, insufficient sleep, too long hours shut 
up in class-rooms, and employment out of school hours. 1 

1 An extreme instance of the effect of these conditions was brought before the 
Royal Society of Medicine (May 26, 1916) by Dr. Cautley, who exhibited a boy 
aged 6 years and 8 months. This boy was only 26£ inches in height and weighed 
only 16 lb. 14 oz. ; he was pot-bellied, markedly rachitic, mentally dull, and ex- 
hibited numerous defects. There was no evidence of disease to account for the con- 
dition. Commenting on the case, Dr. Mitchell Smith said : "I agree with the 
opinion of the chairman. This child has not had a fair chance since its conception. 


Defective Teeth. — This is the commonest defect found 
in school children. The statistical returns from different 
school areas show a wide range of variation in the percent- 
age of school children who display this condition, but un- 
doubtedly the variation depends to a considerable extent 
upon the thoroughness and skill with which the teeth are 
examined. When a group of children are examined by a 
dentist, with the aid of a reflecting mirror and probe, some- 
times not a single child will be found with an absolutely 
perfect and complete set of teeth. Obvious and serious 
decay affecting several teeth is exhibited by from 50 to 90 
per cent of school children. The condition becomes worse 
as the child grows older, and at the leaving age many of 
the permanent teeth are already badly decayed. The 
condition of the teeth in many young domestic servants 
and in recruits is often exceedingly defective. The worst 
effects of decayed teeth are the secondary diseases which 
they set up, such as abscess of the jaw, enlargement of the 
glands, which may become tuberculous, digestive disorders, 
anaemia, and ' rheumatism.' These evils are more manifest 
in adults than in school children. 

We are steadily increasing the number of dental clinics, 
etc., for curing defectiveness of the teeth, but there is 
little reason to doubt that the condition could be largely 
prevented by suitable feeding. Dr. Sim Wallace, 1 Dr. 
Wheatley, and others have shown that decay of the teeth 
is mainly due to feeding children on soft, pappy, starch- 
containing foods, and their excessive eating of sweets. The 
appearance of the teeth is Nature's indication that the child 
should be given food which requires chewing, particularly 
fibrous fruit, at the end of a meal, and where this has been 

The mother is not a robust woman, and the last four babies were born within a 
period of three years and four months. In addition to suckling the previous child 
up to the date of this child's birth, the mother shared her supply between the two 
children for some time. From 18 months to 3 years old the child was fed on Nos. 
1 and 2 Allenbury, and was also given 20 minims of brandy daily to assist its 
growth. So far as I could ascertain he had no fresh milk till he was over the age 
of 3 years, and since then ho has had one pint or less per diem. The child has been 
equally unfortunate as regards a proper supply of fresh air and sunlight. He has 
never been in the covintry, and has spent practically all his life indoors at his home, 
which is in a poor low-lying district in the Potteries. The home is clean, but ill-lit 
and overcrowded, and he is only in the fresh air when his mother can find time to 
take him out in the perambulator." 
1 Prevention of Dental Caries, 1912. 


done astonishing results have followed. It is an interest- 
ing fact that the worst condition of the teeth is found 
among children in good - class schools. In the poorest 
schools the children have better teeth and retain their 
temporary teeth for a longer period, probably because 
they eat fewer sweets and because, as Sir George Newman 
has pointed out, neglected children " are left to pursue 
their natural aptitude for chewing uncooked fruit and 
vegetables." Here we have probably an instance of real 
maternal ignorance, but it is doubtful whether many of 
those appointed to dispel this ignorance are much better 
informed than the mothers themselves. It will probably 
be many years before parents cease to regard decay of a 
child's teeth as inevitable ; and abandon the belief that the 
condition is due to inherited defectiveness of their own 

Uncleanliness in school children, though substantially 
reduced in recent years, is still widely prevalent. Pediculi 
appear to be present in rather more than 2 per cent of 
school children, but nits in the hair are found in over 20 
per cent of the children in many schools, particularly 
among girls, owing to their longer hair. These conditions 
reduce the general health of the child, the constant irrita- 
tion is apt to produce nervous disorders, and the scratch- 
ing of the skin may lead to serious septic conditions. 
Further, it is possible that infectious disease among 
children may be spread by vermin. 

Other conditions of ill-health met with in school 
children are diseases of the nose and throat ; discharging 
ears, " the most serious and difficult problem of all the 
diseases dealt with as ' minor ailments ' " ; defective 
vision ; and disorders of the heart and lungs. 

Defectiveness among School Children in 
Urban and Rural Areas 

As with mortality, the great cause of defectiveness in 
school children is an urban environment. Industrial 
towns are the worst, but residential towns show an appreci- 
able excess over rural areas, particularly in the graver 


conditions of diseases of the ears, the heart, and the lungs. 
The following table from Sir George Newman's report for 
1914 shows the distribution of defects in the three types 
of areas, and also gives us a picture of the deplorable 
condition of school children in industrial areas at the end 
of school life, in spite of the medical service, feeding, and 
other efforts at improvement. 

Physical condition, etc. 


of defective leavers in 


14 Industrial 

15 Residential 

11 Rural 


Towns, f 

Areas. J 

Uncleanliness of head . 




Uncleanliness of body . 







Diseases of nose and throat 


17-3 15-7 

External eye disease . 


2-0 1-9 

Defective vision .... 


29-1 19-2 

Diseases of ears .... 


24 14 

Defective hearing .... 


4-2 1-9 




Diseases of heart and circulation 




Diseases of lungs .... 




* The industrial areas were : Birkenhead, Bradford, Bury, Hull, Leicester, 
Manchester, Northampton, Pontypridd, Sheffield, South Shields, Tynemouth. 
Wallasey, Wallsend, Wolverhampton. Total number of leavers inspected, 56,163. 

•f The residential towns were : Beckenham, Blackpool, Bromley, Chester, 
Colchester, Gloucester, Hastings, Margate, Richmond, Salisbury, Shrewsbury, 
Southport, Taunton, Torquay, Weymouth. Total number of leavers inspected, 

J The rural areas were : Cornwall, Devon, Essex, Norfolk, Oxon, Somerset, 
Westmorland, Isle of Wight, Wiltshire, Yorks East Riding, Yorks North Riding. 
Total number of leavers inspected, 45,015. 

Kural areas have an advantage throughout, but the 
greatest difference occurs in diseases of the lungs, which 
are nearly four times as high in industrial areas, again 
pointing almost certainly to the influence of smoke. The 
residential towns show a much smaller increase in diseases 
of the lungs over rural areas, but we may notice from the 
list that nearly all these towns were of an open character 
or were seaside places, and, with the exception of Black- 
pool, all had low rates of infant mortality. The pro- 
portion of children suffering from malnutrition in rural 


districts seems higher than might have been expected, 
but probably each medical officer takes more or less as 
his standard the average for the district, and if urban 
and rural malnutrition were both measured by the same 
standard it appears likely that the difference would be 
considerably greater. Diseases of the nose and throat, 
which are mainly enlarged tonsils and adenoids, also 
cannot be measured by any definite standard. 

The causes of defects in school children will not be 
further examined here, since they are essentially the same 
as those producing ill-health in all classes of the com- 
munity. There is, however, one special cause, affecting 
mainly boys, which may be conveniently dealt with at 
this point, and that is the employment of school children 
out of school hours. 

Employment of Children out of School Hours 

Year after year Sir George Newman calls attention in 
his annual reports to the harm done among school children 
by this practice, and strengthens his protests by quoting 
numerous extracts from reports of school medical officers 
and teachers. We learn from these that large numbers 
of boys are employed in delivering milk or newspapers in 
the early morning hours before school opens, or in running 
errands or working often late into the evening after school 
hours. During the war the employment of children has 
largely increased ; we will not, however, examine the evil 
under abnormal conditions, but will note some of the 
instances of such employment, and its effect on health 
during the year 1914. 

The school medical officer for Jarrow reports : — 

Some of these boys go out with papers as early as 5.30 a.m., 
and many are crying papers imtil 10 p.m. or later. The teachers 
tell me that they often fall asleep during morning school and are 
quite incapable of sustained work. Many of these paper boys work 
on Saturdays and Sundays, the total number of hours per week 
reaching 30 or over in quite a number of cases. 

From Manchester : — 

6081 children were employed out of school hours for wages . . . 
156 children of 7 and 8 years of age (including 94 girls) are working 


out of school hours. Of these 96 (including 52 girls) are going 
errands, that is, delivering milk, papers, and goods for small shops. 
Domestic work and ' minding ' babies account for 36 girls and 2 
boys. Two boys of 8 years of age are engaged in delivering coal 
from retail coal-yards. . . . The boys not only showed a decided 
inferiority in mental capacity and attainment, but are also lower, 
distinctly so, in moral tone. . . . One boy aged 13 works nearly 3 
hours before morning school, 3| hours each evening, 12| hours on 
Saturday, and 5 hours on Sunday. 

From Plymouth : — 

In many cases the boys are suffering physically and mentally 
from overstrain. Some of them come to school at 9.45 utterly unfit 
for school work. . . . Children are described as follows : ' Frequently 
drops asleep in school ' ; ' pale and fagged ' ; ' nervous and very 

From Tynemouth : — 

Incidentally I discovered that there were still certain boys 
employed as late as 10 o'clock on a Friday night and 11 o'clock on 
a Saturday night, though this became in March of this year a punish- 
able offence on the part of the employer. 

From York : — 

There is undoubtedly need for some carefully-planned regula- 
tion of the employment of children ; otherwise children are ex- 
ploited to their excessive fatigue, insufficiency of sleep, arrest of 
growth, and general physical detriment. 

It will be noticed that these reports, and many similar 
which could be quoted, all refer to running errands, selling 
goods, etc., in large towns. There is very little evidence 
in any reports that agricultural employment— at least if 
supervised — is harmful to boys. The school medical 
officer for Rutland makes the following report, in which 
however he does not specifically state the occupations of 
the boys, though it may be inferred that they were mainly 
agricultural : — 

Ninety-seven children, 87 boys and 10 girls, worked out of 
school hours, and a careful examination of their condition as com- 
pared with other children inspected was made and displayed in a 
table of percentages. . . . These figures go to show that in the aggre- 
gate no harm is done to the children working out of school hours. 
Nutrition is certainly better among the workers, cleanliness is not 
appreciably affected, and the condition of the teeth, nose, and 
throat is distinctly better among the workers. 


Most significant too is the report of the school medical 
officer of Dorset, where the County Education Committee 
has consented to the employment of children of school age 
on agricultural work only. He says : "As regards the 
physical condition of the children who had been exempted 
for agricultural employment, I was informed by the head 
teachers that in a number of instances marked improve- 
ment had been noticed in the health of the children after 
being so employed." x 

The School Medical Officer for Lancashire also finds 
agricultural work beneficial. He says : — 

Lighter forms of agricultural work such as weeding root crops, 
potato picking, and milking are not unsuitable for half-time 
children. Many of our school children are engaged in potato 
picking annually, and there is no evidence that their health is 
prejudiced thereby. The children who have been taking the milk- 
ing classes instituted by the Lancashire Education Committee have 
improved in health. 2 

The question as to the relative effects on health of 
different kinds of employment in different types of areas 
demands further investigation, but these reports appear 
to show that the evil is mainly one relating to errand work 
in towns. The writer — who may perhaps unduly prefer 
the claims of health to those of education — would go so 
far as to urge, if possible, that all older school children 
should be turned out of the large towns to work in the 
fields, under suitable restrictions, during the summer 

The system of permitting ' half-timers ' to work is 
allowed by law, subject to restrictions relating to hours 
and conditions of work. If these regulations were strictly 
observed the practice would still be sufficiently undesirable, 
but there is evidence in many districts of open and whole- 
sale disregard of the law. The Board of Education report 
shows that in Liverpool the by-laws had not been com- 
plied with in 161 instances among 1059 boys, and 3 out 
of 17 girls were employed illegally ; and the school medical 
officer at Bromley says, " infringements of these by-laws 

1 Report of Chief Medical Officer to Board of Education for 1915. 
2 Ibid. 


are at present terribly frequent." The worst case was at 
Margate, where among 166 boys employed, 114 were 
illegally employed. 

Seventy years ago Lord Macaulay, speaking in defence 
of a Bill for limiting the labour of young persons in factories 
to ten hours a day, said : " Rely on it that intense labour, 
beginning too early in life, continuing too long every day, 
stunting the growth of the body, stunting the growth of 
the mind, leaving no time for healthful exercise, leaving 
no time for intellectual culture, must impair all those 
high qualities which have made our country great. Your 
overworked boys will become a feeble and ignoble race of 
men, the parents of a more feeble and more ignoble 
progeny. . . . Never will I believe that what makes a 
population stronger and healthier and wiser and better, 
can ultimately make it poorer." * 

Conditions have improved since these words were 
spoken, nevertheless, though two generations have elapsed, 
the reports of the Board of Education every year reveal 
to us that early labour is spoiling the growth and impair- 
ing the prospects of large numbers of children in all our 
great cities. 

Children in Special Schools and Institutions 

The state of the ordinary school child as shown by the 
records is bad enough, yet it does not represent the full 
tale of ill-health among children. As we have noted, the 
worst cases of defectiveness have been sifted out of the 
child population, and are to be found in the special schools 
for mentally and physically defective children, in the 
institutions for the treatment of tuberculosis, ophthalmia, 
ringworm, etc., the Poor Law infirmaries, and the institu- 
tions of the Metropolitan Asylums Board. Sir George 
Newman estimated the dull or backward, physically 
defective, epileptic, mentally deficient, deaf and dumb, 
and blind children at 131,250 in 1914. In addition there 
were on January 1, 1915, in lunatic asylums and Poor Law 
institutions, 18,483 children below the age of sixteen 

1 House of Commons, May 22, 1846. 


who were suffering from sickness, accident, or bodily 
or mental infirmity. In the hospitals and schools of 
the Metropolitan Asylums Board for sick and debilitated 
children, and those suffering from ringworm or ophthalmia, 
5856 were under treatment during 1914, in addition to 
38,862 persons — the great majority being children under 
fifteen — who were treated in the fever hospitals for in- 
fectious disease. In none of these statistics are repre- 
sented sick or defective children who are kept at home. 

The Folly of Palliative Measures 

The appalling mass of disease and defectiveness among 
children represents much pain and misery, and great 
economic loss to the community, for many of these children 
are impaired throughout life. And yet the great bulk of 
it could be avoided. The overwhelming cause is clearly 
an urban environment, particularly that of large indus- 
trial towns, but we do relatively little to counteract this 
influence. Our efforts to clear slums and establish open 
spaces are not nearly great enough ; we continue to build 
our schools in close proximity to gasworks, factories, and 
noisy main-roads ; and we provide them with stone- 
paved courts which are wholly insufficient and inappro- 
priate as playgrounds. Instead of attacking the causes 
of disease, we have established an elaborate and much- 
vaunted system of medical inspection, which examines a 
child once in three years in order to detect ' incipient ' 
maladies ; and an inadequate scheme for medical treat- 
ment which only succeeds in reaching about half the 
children reported as requiring medical attention, and then 
only classes as ' remedied ' less than 60 per cent of those 

The folly of this system is manifest. Preventive 
measures benefit all classes of the community at once ; 
curative measures benefit only the one class, and that prob- 
ably only to a limited extent so long as environmental con- 
ditions are unsatisfactory. At present we deal with persons 
in isolated groups, and we act as though we believed 
that disease is a different thing in infants, children, 


paupers, insured persons, etc., instead of realising that to 
a large extent the main diseases are the same, and that to 
a much larger extent the main causes of preventable dis- 
ease are the same throughout the country in all classes of 
the community. Palliative measures mean infant clinics, 
medical inspections, treatment centres, panel services, 
sickness benefit, hospitals, infirmaries, and sanatoria. 
Preventive measures are open spaces, larger playgrounds, 
clearing of slums, segregation of factories, wider streets, 
increased means of transit, and scattering of the people in 
crowded areas over outlying districts. It is for the com- 
munity to choose which it will have. 

Sickness in Adults 

We possess now a good deal of information relating to 
the amount and distribution of sickness apart from 
mortality, from the returns which are issued by Approved 
Societies under the Insurance Act. We must however 
note here also that the insured population is selected, and 
does not give us a true picture of the average health of the 
community. The Act applies only to the working part 
of the populace, and the returns do not therefore show 
sickness among cripples, insane persons, and others pre- 
vented by permanent incapacity from coming under its 
provisions ; moreover, it excludes casual labourers, who 
form one of the unhealthiest sections of the working classes. 
Further, some three-quarters of insured persons are men, 
who as a class have a lower average sickness-rate than 
women. Even for insured persons, the returns do not 
include that sickness which does not entitle to benefit on 
the ground that the patient was suffering from a disease 
the result of his misconduct, or was in arrears with his 
contributions, or otherwise ineligible. Yet even these 
incomplete returns have shown that there is an appalling 
amount of sickness, particularly among women. It is now 
known that nearly all the women's societies except those 
consisting of lives above the average, such as domestic 
servants, are insolvent, in some of them the actuarial 
estimate having been exceeded by as much as 100 per cent. 



Among men's societies many which contain a large pro- 
portion of coal-miners, quarrymen, steel-smelters, boiler- 
makers, and others engaged in unhealthy trades have 
considerably exceeded the standard. 

Rural and Urban Sickness 

The distribution of sickness teaches the same lesson 
as that afforded by mortality and defectiveness in infants 
and children. Unfortunately we cannot express sickness 
in relation to the same areas as those employed by the 
Registrar - General for mortality, an instance of unco- 
ordination in Public Health statistics which, as we shall 
see later, is very characteristic. We must have recourse 
therefore to the returns issued by individual Approved 
Societies, and as an example the following average amounts 
paid per member in different counties by the Manchester 
Unity Society during the nine months ending July 5, 1914, 
may be quoted : — 

s. d. 
Durham . . . 12 2 


10 10 

Derbyshire . 

10 7 
10 4 


7 10 

Kent . 

7 7 

Hampshire . 

6 11 
6 11 

It should be noticed that these figures do not represent 
the difference between exclusively urban and rural areas, 
but only those between counties mainly urban and mainly 
rural. The full difference between rural and urban areas 
would be even greater than that shown in the table. 
Moreover, the figures should be corrected for sex and age, 
the effect of which would probably be still further to 
increase the difference, since the average age is appreciably 
higher in rural districts than in towns, and probably there 
was a larger proportion of men in the Durham and North- 
umberland societies than in the rural counties. Many other 
reports could be quoted to show that sickness in urban 
environments is very considerably higher than in rural areas, 
but it is not necessary to do this, for indeed the difference 


exhibited by the people living in these two types of environ- 
ment is patent to any observant person who mixes with 
the working classes. The contrast between the healthy 
frame of the average country woman and the pallid faces, 
blotchy skins, and poor physical development of many of 
the women in the poorer parts of large cities can scarcely 
escape notice. 

It may be observed that since the incidence of sick- 
ness is so unequal, the flat rate of contribution under the 
Insurance Act invalidates the fundamental principle of 
insurance, which demands equality of payment for reason- 
able equality of risk. 1 This principle is recognised in the 
system of fire insurance, premiums being raised when a 
building is situated in a specially dangerous area or subject 
to exceptional risk, and lowered where the owner agrees 
to observe special precautions. But under the Insurance 
Act rural contributors are paying for the benefits of 
urban contributors. It is true that in theory rural workers 
need not lose, since they can form their own societies. 
But in practice the Act has not worked in this direction, 
the tendency having been towards the formation of large 
societies which draw their members from all parts of the 
country, and grow continually by the absorption of smaller 
societies. None the less it is the gain on the rural 
members which compensates or helps to compensate for 
loss on members in unhealthy towns. It is, indeed, this 
factor which has kept some societies solvent, for if rural 
workers had everywhere kept themselves separate, a larger 
number of urban societies w T ould have been in financial 
difficulties. Broadly speaking, it may be said that the 
agricultural South of England is paying for the industrial 
North ; and the ultimate effect is to impose a tax upon the 
agricultural labourer, the most poorly-paid manual worker 
in the community, for which he gets no fair return ; and 
upon rural industries, which of all in this country we ought 

1 Mr. Bathurst several times called attention to this effect of the Insurance Act 
during the debates in the House of Commons. Speaking on the Amendment Bill 
he said : " As long as the flat rate of payment remains, the agricultural labourers 
and their employers have a well-founded grievance " ; and he supported his views 
by quoting the experience of " the largest rural workers' Friendly Society in the 
kingdom," which, on the actuarial estimate, should have received £8200 in the 
quarter, but did, in fact, receive only £4869. — Parliamentary Debates, vol. 55, No. 79. 


most to encourage. How little this seemingly obvious 
development was foreseen may be judged from the follow- 
ing extract from one of Mr. Lloyd George's speeches : — 

The rural workman will be a different being with a powerful 
organisation at his back. He will no longer tolerate some of the 
wretched conditions under which he now lives — too often dark and 
dank cottages held on precarious tenures ; too often in many 
counties miserable wages for long hours — tricked out of his commons 
by the ancestors of persons who send him to gaol because he traps 
a hare which may scamper across the commons that belonged to 
his fathers ; land which was formerly his own let out to him re- 
luctantly by the pennyweight as if every grain of it glinted with 
radium. The first message of real hope that he received was the 
old age pension. That made him a free man — after seventy. The 
organisations which he will form under this Act will help to free him 
for the rest of his life. The labourers of ancient Rome were only 
allowed to organise themselves for burial purposes. They used 
those organisations to discuss other matters, including the greatest 
matter of all. And my own opinion is that these societies formed 
in rural areas for provident purposes will help eventually to win 
for the agricultural labourer a treasure more valuable than any you 
can put in an Act of Parliament — his independence. 1 

These flights of imagination would be harmless in an 
ordinary person, but when in place of hard facts they 
influence the actions of one who has power to initiate vast 
and costly social changes, they demonstrate the necessity 
of placing consideration of Public Health measures in the 
bands of those who have some knowledge of the subject. 

Defects among Army Recruits 

The return of the reasons for which army recruits are 
rejected gives us some indication of the prevalence of 
physical defects in the adult male population. Figures 
are not available for the period of the War, though it is 
known that the number of rejections has been large, 
despite a substantial lowering of the standard. The 
following table from the Board of Education Report gives 
the chief defects for which recruits were rejected in 1912: — 

1 Times, February 13, 1912. 


Recruits rejected from October 1, 1911, to September 30, 1912 
Total number inspected, 47,008. 

Cause of Rejection. 

Impaired constitution and debility- 
Defective vision 
Diseases of eyes and eyelids . 
Diseases of nose and mouth . 
Diseases of ears . 
Deafness .... 
Loss or decay of many teeth . 
Flat-feet .... 
Malformation of chest and spine 
Under height 
Under chest measurement 
Under weight 
Other defects 


Rate per 1000 











It will be noticed that nearly one-quarter of all who 
offered themselves were rejected. The fine appearance of 
bodies of troops marching through the streets creates in 
the public mind an impression of the vigour of British 
manhood. But it is forgotten that these men are selected, 
and a morning spent with the Medical Officer of a 
recruiting station will give a very different picture of 
physical conditions among large masses of the male 
population in these Islands. 

The Number and Distribution of Deaths from 
the Principal Diseases 

This chapter may be concluded by a general examina- 
tion of the diseases which are responsible for the greatest 
numbers of deaths. The International List of the Causes 
of Deaths contains 189 headings many of which have sub- 
headings, nevertheless the great bulk of deaths are caused 
by quite a small number of diseases or groups of diseases. 
The following table shows the more important causes or 
groups of causes which were responsible for mortality in 
England and Wales in 1914 : — 



Causes of Deaths in England and Wales, 1914 

Respiratory diseases — 

Bronchitis . 

. 40,189 

Pneumonia . 

. 40,070 

Pulmonary phthisis 

. 38,637 

Measles and whooping-cough 

. 17,184 

Other respiratory diseases . 

. 6,109 

Total respiratory diseases 


Diseases of heart 


Diseases of blood-vessels (including 



Cancer . 


Premature birth, etc. . 


Diarrhoea and enteritis 


Nephritis and Bright's disease 



Non-pulmonary tuberculosis . 


Violence . 


Old age . 


Other causes . 



All causes 


We see from this table that, in the aggregate, respira- 
tory diseases account for more than one-quarter of the total 
mortality from all causes; a very significant fact, which 
shows that in his present environment man's lungs are by 
far his most vulnerable organs and the most likely to 
become the seat of disease. 

The distribution of the mortality from all causes accord- 
ing to types of area is shown by the following table in which 
the death-rates have been standardised, that is, corrected 
for differences in age and sex constitution so as to render 
them comparable : — 

Death-Rates from all Causes, 1914 

England and Wales 


London ..... 


County Boroughs of North 


„ ,, Midlands 


„ ,, South 


Rural Districts of North 


„ „ Midlands 


„ „ South 


We notice that the standardised death-rate in the 
County Boroughs of the North is 85 per cent higher than 
that in the Rural Districts of the South. 



An examination of the distribution of the causes most 
frequently responsible for death will indicate the directions 
in which the greatest scope now lies for preventing disease 
and improving the Public Health. 


Tuberculosis is the most deadly disease from which 
we suffer, being responsible for more than 10 per cent of 
the total deaths from all causes in the British Isles, and 
probably for much more than 10 per cent of the total 
sickness. The following table shows the death-rates from 
tuberculosis in different types of area : — 

Death-Kates per Million from Tuberculosis, 1914 




County Boroughs of North 
„ ,, Midlands 
„ „ South 

Rural Districts of North 

„ , ; Midlands . 
„ „ South 









We may notice that the death-rates among males are 
considerably higher throughout than among females, a fact 
of much interest, the precise causes of which require further 
investigation. As regards geographical distribution there 
is no doubt that the differences in the table appreciably 
under-represent real differences, owing to the tendency of 
tuberculous persons to migrate from urban to rural or sea- 
side localities as soon as the disease is detected ; and since 
illness is usually long enough to lead to the death being 
registered in the new district, the result is to lower the 
urban and raise the rural rate. It has long been recog- 
nised that the death-rate in the County Boroughs of the 
South is swollen by the consumptives who migrate to and 
die in the seaside resorts along the south coast, while 
deaths in smaller places raise the rural rate. 1 It is known 

1 Dr. Newsholrne has discussed this point in his Report for 1912-13. 



too that a certain number of young persons who migrate 
from the country to towns acquire the disease in their new 
environment, and return to their old homes to die. This 
would be more likely to happen in the Eural Districts of 
the South than those of the North, for if a miner develops 
tuberculosis he will probably die in his native village, but 
a London servant or shop-girl with a home in the country 
will probably return there. There can be little doubt that 
if the statistics for the Rural Districts of the South repre- 
sented only native cases, the death-rate would be consider- 
ably lower even than that shown in the table. 

The death-rate from phthisis among coal -miners is 
lower than that among persons engaged in other forms 
of mining and unhealthy occupations, which is perhaps 
another reason why the death-rate from tuberculosis in the 
Rural Districts of the North approximates more to the 
general rural rate than do the death-rates from other 
diseases in these districts. The question of occupation in 
relation to tuberculosis, with which is probably associated 
the difference in male and female death-rates, still offers a 
considerable field for research, though admittedly much 
has been done in this direction. Tuberculosis, however, is 
in both sexes essentially a disease of the large industrial 
towns, and it may be of interest to compare the rates in 
some of these with those in counties mainly agricultural. 



Million fkom Tuberculosis, 1914 

County Borough or Town. 

Administrative County. 

Dublin .... 3565 









Surrey .... 






Salford . 






Dorsetshire . 




Gloucestershire . 


Liverpool . 




Glasgow . 






Swansea . 





The following table from the Report for 1913 of the 
Chief Medical Officer to the London County Council, show- 
ing the rates for the years 1908-12 in certain Metropolitan 
Boroughs, is also very striking : — 

Death-Rates from Phthisis in certain Metropolitan 







Finsbury . 
Holborn . 
Stepney . 

Stoke Newington 
Wandsworth . 







As with infant mortality, the highest death-rates are 
in the central area, and the lowest in the peripheral 

Pneumonia, Bronchitis, Measles, and Whooping- 


The distribution of these conditions in 1914 is shown 
in the table on the following page. 

Again we notice in all three diseases the marked differ- 
ence between urban and rural death-rates, and particularly 
between the rates in the County Boroughs of the North 
and the Rural Districts of the South. We notice further, 
in pneumonia the considerably higher death-rate among 
males than among females, probably owing to a larger pro- 
portion of the former being engaged in dust-producing 



Deaths per million. 







County Boroughs of North 



„ ,, Midlands 



„ ,, South 



Rural Districts of North 



,, ,, Midlands 



„ „ South 




London ... ... 



County Boroughs of North 



,, „ Midlands 



,, „ South 



Rural Districts of North 



,, „ Midlands 



,, „ South 



Measles and Whooping -Cough 



County Boroughs of North 



,, „ Midlands 



„ ,, South 



Rural Districts of North 



,, „ Midlands 



„ „ South 



occupations, such as quarrying, and cutlery and pottery 

Diseases of the Heart and Blood-Vessels, Nephritis, 
and Bright's Disease 

This group of diseases stands in marked contrast to those 
from respiratory affections, in that the death-rate varies 
very little in different types of area and between the two 
sexes, though for heart-disease the rate among women is 
slightly higher than among men. It is clear therefore 
that the general environment exerts only a minor influence, 
if any, upon the incidence of these diseases, and the power 


of the State to prevent them is limited. Heart-disease and 
allied conditions are due to a number of causes, including 
congenital defects, acute illnesses (particularly rheumatic 
fever), and pathological changes which are frequently 
associated with heavy and prolonged muscular exertion, 
syphilis, and alcoholism. State effort might bring about 
a reduction of deaths from the last two causes, of which 
syphilis will be examined later. Alcoholism is responsible 
not only for deaths from heart-disease, but for affections 
of the liver and other organs, and the habit undoubtedly 
increases the liability to pneumonia. Prevention of 
alcoholism is however more a social than a Public Health 
problem, for action by the State is limited to restriction 
of the drink traffic, abolition or control of public- 
houses, and educational measures. Any great or lasting 
improvement must come from increased self - control 
among the people themselves. It is for these reasons 
that not much is said about alcoholism in this book, but 
it must not be inferred that the writer does not fully 
appreciate the great amount of disease for which it is 


Preventive medicine has unfortunately almost no con- 
cern with cancer. We do not know the causes of this 
disease nor the conditions which lead to it, except that it 
sometimes follows chronic irritation. Cancer belongs to 
the domain of the surgeon, who undoubtedly saves large 
numbers of lives ; and all that public authorities can do is 
to emphasise the importance of early diagnosis and treat- 
ment. Geographically the standardised mortality increases 
with urbanisation, the deaths per million in 1914 having 
been 864 in the Rural Districts of England and Wales, 
976 in the smaller urban districts, 1040 in the County 
Boroughs, and 1111 in London. These differences how- 
ever may have been due to better diagnosis and perform- 
ance of more autopsies in the large towns. Mortality from 
cancer has apparently been increasing for many years, but 
again, part at least of this is due to better diagnosis, while 



the crude rate has risen somewhat owing to the increasing 
proportion of persons in the community at ages at which 
the disease is most prevalent. 


We have already considered these conditions in infants, 
among whom three-fifths of the total deaths occur, but it 
may be useful to tabulate the differences between urban 
and rural environments for the total deaths. 

Deaths per million. 




County Boroughs of North . 

,, „ Midlands 

„ „ South 
Rural Districts of North 

„ „ Midlands . 

,, „ South 

338 / 


In London, in 1913, the death-rate of infants under 
two years of age per thousand births from diarrhoea 
was 59 in Shoreditch, 42 in Bermondsey, 14 in Stoke 
Newington, 14 in Lewisham, and 13 '5 in Hampstead. 


Syphilis, according to the tables of the Registrar- 
General, was responsible in England and Wales in 1914 
for only 2146 deaths, of which 1361 were of children under 
one year of age. These figures do not however represent 
the total mortality, partly because the real nature of the 
death is sometimes withheld from the certificate, and partly 
owing to the death being certified under some condition, 
such as paralysis or degeneration of the arteries, to which 
the disease has led. The ravages of syphilis are to be 
measured much more by the sickness and pathological 
conditions it produces than by its mortality, for the disease 
is not one which kills quickly, and there is probably no 


disease — not even cancer — in which the sickness and 
secondary complications bear so large a proportion to the 
mortality as syphilis. It may attack and injure or destroy 
any organ of the body, and the nose, eyes, ears, throat, or 
skin. It is an important cause of heart-disease, Bright's 
disease, arterial degeneration, aneurism, paralysis, and 
insanity ; and it appears to be responsible for perhaps 
15 to 20 per cent of still-births. As we have seen, it is not 
a large cause of infant mortality. The Royal Commission 
on Venereal Diseases estimated that in large cities the 
number of persons who have been infected with syphilis, 
acquired or congenital, is not less than 10 per cent of the 
population, though they point out that they were unable 
to obtain any positive figures. This is an unexpectedly 
high estimate, and to the writer the evidence upon which 
it was based does not appear convincing ; but in any case 
the extent of the disease — though probably exaggerated 
in the public mind — is sufficient to justify action by the 
State which seems likely to lead to its reduction. 

Syphilis is essentially a disease of large towns. The 
Commissioners say : " County Boroughs return the highest 
mortality under each heading in the four divisions of the 
country dealt with, and are followed at some distance by the 
smaller towns, while the rural mortality is low in every 
instance." The experience of practitioners in regard to 
sickness from syphilis is the same. Witnesses before the 
Commission stated that in the rural parts of Ireland the 
disease is practically non-existent, and many practitioners 
had not seen the disease for years except in an occasional 
tramp. The worst foci of the disease appear to be the 
large seaports. In Sweden, where the disease must be 
notified, the distribution is the same, the incidence of new 
cases in 1914 having been 217 of the population in Stock- 
holm, 26 per cent in the smaller towns, and 0"02 per cent 
in the country districts. 

Following the recommendation of the Royal Com- 
mission, steps are now being taken to provide free treat- 
ment for those suffering from the disease, and in view of 
the facts that modern discoveries have much improved the 
methods of treating syphilis, and that the facilities of 


higher treatment have hitherto been seriously inadequate 
among the working classes, this provision should be of con- 
siderable value. The criticism may be made however, 
that since 75 per cent of the cost of treatment is to be met 
by Government grants, rural districts free from the disease 
are being made to pay a part of the cost of syphilis in 
towns ; whereas if each locality was obliged to pay the 
cost of its own sickness — not only from syphilis, but from 
other conditions — local authorities would have a strong 
inducement to adopt measures for the prevention of 

The prevention of syphilis is a difficult problem, and 
one which cannot be examined from the Public Health 
aspect only, since it involves social and moral questions, 
discussion of which is outside the scope of this book. 
The giving of lectures and advice to young persons is a 
desirable measure, as is also the providing of healthy forms 
of recreation, which witnesses before the Commission stated 
had had an appreciable effect in reducing the disease among 
soldiers. Certain prophylactic measures have been en- 
forced in the Navy for a number of years, in the opinion of 
competent authorities with great benefit ; and since 1911 
the Board of Trade has encouraged their adoption in the 
merchant service. The Royal Commission did not how- 
ever refer to these methods in their report, and since they 
were required to examine the question from every point of 
view, it must be assumed that, in their opinion, objections 
to spreading knowledge of these methods outweighed any 
advantage to health which might result from them. 

The recorded mortality from syphilis fell from 89 per 
million in 1875 to 51 per million in 1911, though the greater 
part of this fall was previous to 1901, the figures since that 
date having fluctuated only between narrow limits. These 
figures are of course quite useless as an absolute measure, 
though there is no obvious reason why they should be 
rejected as an indication of a real decline in the incidence 
of the disease ; the Commission however did not accept 
the view that they represented a real fall. On this point 
Dr. Stevenson pointed out that if the actual incidence of 
the disease had remained constant there are several 


important factors which would have tended to increase the 
recorded death-rate, such as : improvement in diagnosis ; 
the large increase in the proportion of deaths from all 
causes which occur in institutions and are more likely to 
be accurately certified ; and the increase in the proportion 
of the urban population, which, since syphilis is essentially 
a disease of large towns, should have markedly increased 
the death-rate. A further indication of reduction of the 
disease in the civil population is afforded by the decrease 
in the proportion of recruits for the army rejected for 
syphilis, the rate having been 16 5 per thousand in 1873, 
6 3 in 1890, and 1*4 in 1911-12. The Commissioners ex- 
plain the decrease — at least since 1890 — in the following 
words : " It is probable that the signs of the disease are 
' better known than formerly, and that men recognising 
' these signs may not offer themselves as recruits. Further, 
' recruiting sergeants seeing that candidates are diseased 
1 may tell them to get cured before presenting themselves 
' for medical examination. Again, soft chancre was not 
' definitely distinguished in the statistics from syphilis till 
' about 1892, and since 1901 there has been a rise in the 
' percentage of rejections from ' other diseases of the genital 
' organs,' which may be due to transference from the cate- 
' gory of syphilis, thus diminishing the percentage ascribed 
' to the latter disease." It is difficult however to regard 
this statement as a convincing explanation of the decline, 
for the signs of the disease recognisable to the affected 
man have not changed ; it is impossible to believe that 
recruiting sergeants can pick out four or five men from 
the half-dozen or so in every thousand who are suffering 
from syphilis ; and the report nowhere states the per- 
centage which have been transferred from ' syphilis ' to 
' soft chancre.' 

Several medical witnesses of wide and long experience 
expressed the opinion that syphilis has shown a decline 
both in extent and virulence during the last thirty years, 
and to the writer the evidence given before the Commission 
seems to point strongly to this being a sound conclusion. 
It is difficult to read the report without gaining the im- 
pression that, bad as syphilis is, the Commissioners have 



made the worst of the case. They appear to have strained 
the evidence in two directions : increasing on the one hand 
the number of still-births due to syphilis, and the total 
prevalence of the disease ; and minimising on the other 
the indications that it has declined. The writer does not 
presume to question the value of the consideration given by 
the Commission to difficult social and moral questions ; but 
if his criticisms are justified, they illustrate the disadvan- 
tages of entrusting the investigation of purely scientific 
questions to Royal Commissions, a point to which further 
reference will be made. 

The review in this and the preceding chapter of the 
state of Public Health in England at the present day shows 
that the condition of large masses of the population is 
thoroughly unsatisfactory if measured by the healthiest 
communities. Mortality among infants and young children 
is at least twice as high as it need be ; defectiveness is wide- 
spread among school children ; rejections of army recruits 
are high ; preventable diseases claim many thousands of 
lives ; and the death-rates in the rural districts of the Mid- 
lands and South show that the present rate for the whole 
country would be reduced by at least a quarter if the 
healthiest conditions were universal. We have fallen 
into the habit of regarding Public Health efforts in this 
country with some complacency, and it is true that the 
standardised death-rate has declined 25 per cent since 1881 ; 
but when we deduct from this decline that part of it which 
is due to natural diminution of disease, and that which is 
due to progress in surgery, it is evident that the results of 
our vast volume of preventive efforts are still relatively 
small. It may be that these deaths are preventable only 
in theory, and that in practice economic conditions forbid 
the wide adoption of the measures necessary to prevent 
them ; but if this is so, let us at least realise the price we 
are paying for commercialism — a price which will steadily 
increase unless radical changes are made in urban environ- 
ments. In Ireland the crude death-rate in 1914 was 16 '5 
compared with 14*0 in England and Wales, but the stand- 
ardised death-rate is lower than that in England and 


Wales. 1 This result is due to the higher average age of the 
population owing to the emigration for many years past 
of young people. In France, with only three-eighths of its 
population living in towns of 5000 inhabitants and over, 
restriction of births for many years has led to a death-rate 
which averages about 18. In this country, also, restriction 
of births is steadily raising the average age ; but when event- 
ually our age-constitution resembles that of France or Ire- 
land, we may expect a higher death-rate than those at 
present shown by these countries, siuce so much larger a 
proportion of our population — already nearly four-fifths — 
is urban. 

Another lesson to be learnt from the distribution of 
disease is the importance of localisation of effort. Control 
of the Public Health services is largely central, and we 
continually pass Acts of Parliament which apply equally 
to the whole country. But the rural districts do not need 
these measures — or at least need them to a relatively small 
extent — and we could safely leave them alone for the 
present, neither forcing changes upon them nor requiring 
them to pay for national measures. For instance, to 
establish a national medical service maintained by Imperial 
taxation would be one of the greatest injustices we could 
inflict upon the rural districts. The great centres of 
disease are London and the large industrial and mining 
towns, and it is upon these that attention and effort should 
be concentrated. Probably the best means to achieve 
this would be to decentralise much of our Public Health 
machinery, and increase the powers and responsibilities of 
Local Authorities, proposals which will be examined in 
greater detail in a subsequent chapter. 

We can attack disease by preventive and by curative 
measures. Preventive measures are indissolubly bound up 
with questions of land and housing, and we will examine 
the relation of these factors to Public Health in the next 

1 I.e. standardised in terms of the population of England and Wales. 



Man not biologically adapted to life in towns — Rural depopulation — The 
overcrowding of cities and the means of relief — Segregation of factories 
— Bad housing — The difficulties of clearing slum areas — The cost of 
building — ' Summer camps ' — Sleeping out. 


The deadly effect of urbanisation — particularly its hurt- 
fulness to the organs of respiration in both young and old 
— possesses a profound biological significance. Zoologists 
have shown that species only become gradually adapted 
to their environments as the result of processes which may 
extend over vast periods of time ; and man is not yet bio- 
logically adapted to the environment of densely-crowded 
towns. For hundreds of thousands of years his Paleo- 
lithic and Neolithic ancestors lived under natural con- 
ditions in plain and forest, with caves, tents of skins, or 
huts of clay and twigs for habitations. The era of life in 
cities is only a day in the history of mankind. Even when 
we reach the period of the so-called ' ancient ' civilisations, 
we can trace little resemblance between their greatest 
cities, Babylon, Alexandria, and Rome, and the huge 
aggregations of smoke-covered houses which form the 
modern centres of industry. How recent is the growth 
of these, is shown by the fact that as late as the year 1700 the 
whole population of England was less than that of London 

This abrupt change in man's environment profoundly 
affected all his habits of life. Previously he had lived a 
primitive existence in harmony with his structure, breath- 



ing pure air and obtaining his food directly from the soil 
or by the chase. Within a few centuries he developed his 
commerce, began to use coal, discovered steam-power and 
the application of electricity, dug his mines, and built his 
railways. Thenceforth communities were divided into 
two groups. One group continued to live a healthy life 
in the fields ; the other, and in this country the larger 
group, abandoned the fresh air for the polluted atmo- 
sphere of towns, and devoted itself in dense masses to 
continuous toil in factory or mine. 

But man is not constructed to thrive in this new 
environment, and its effect upon him is precisely the same 
as that which we can observe in wild animals in captivity. 
The death-rate among animals surrounded by unnatural 
conditions is very high, and often their young can only 
be reared by taking the utmost precautions. London 
reads with regret the fate of litter after litter of the cubs 
of ' Barbara,' the polar bear in Regent's Park, which live 
at the most for a few weeks and then die from pneumonia. 
The higher apes suffer severely from tuberculosis, and nearly 
all the mammalian cubs develop rickets. Man in towns is 
subjected to the same conditions and suffers only a degree 
less severely. There is good reason for believing that 
many of the diseases which he acquires in cities are modern 
developments. We can only judge of diseases which leave 
traces in the bones, but rickets was probably unknown 
among the Neolithic folk, and the teeth of these people 
were well formed and extraordinarily free from caries. 1 

It might be urged that since man is ultimately governed 
by natural laws, the change which he has wrought in his 
environment is part and parcel of his natural evolution. 
But this assumes that evolution of society and evolution 
of physical structure are the same ; and raises the diffi- 
cult question of the relations between intelligence and 

1 Professor Keith, describing a number of Neolithic skeletons found in Kent, 
says : " There is not a single carious tooth to be found in the Coldrum collection. 
The teeth are regular in their arrangement, the palates were well formed, but in 
actual size the teeth possess the same dimensions as those of modern English 
people. All these changes which are appearing in the teeth and jaws of modern 
British people, arise, we suppose, from the soft nature of our modern diet. We 
believe that were modern men to resume a Neolithic diet their teeth and palates 
would again be moulded in the ancient manner." — Antiquity of Man, 1915. 


instinct in man's development. Mankind did not 
make the change deliberately and willingly with know- 
ledge of its ultimate extent and effects, but each in- 
dividual was caught up and carried along willy-nilly in 
a great flood of ' progress,' which, once started, rushed 
on uncontrollable. Yet in many little ways we can see 
that an urban environment is opposed to all man's 
fundamental instincts, and he is continually rebelling 
against the surroundings in which he finds himself im- 
prisoned. There is no other species which exhibits the 
same keen desire to escape at every opportunity from its 
customary habitat as town-dwelling man. The rich take 
their holidays in the country, the poor man goes to Epping 
Forest or Hampstead Heath. Yet other animals pass all 
their existence in one environment. The forest-loving 
animal does not seek the plains, the bat shuns the day- 
light, and the mole thrives in his underground burrow 
where the squirrel would die. Man alone, forced into one 
habitat by his work, tries to create another for his leisure. 
The very term ' bricks and mortar ' is used in a sense of 
reproach, yet there is no logical reason why we should not 
admire a collection of houses as much as a collection of 
trees, or why a patch of paving-stones should not appeal 
to us as strongly as a well-kept lawn. The deep-seated 
craving for a sight of something green struggles to find 
expression in the making of gardens around houses, the 
forming of parks in cities, and the planting of trees in the 
streets. Even the humblest classes try to introduce some 
suggestion of the country into their homes. An observant 
person coming into London by one of the main railways, 
which is perhaps the best way of realising quickly the grim 
ugliness and horror of the poorer parts, will continually 
notice stunted plants on the window-sills or nasturtiums 
and Virginia creeper struggling against the sooty atmo- 
sphere. The Biblical chroniclers understood human nature 
when they placed Paradise in a garden and made the first 
man a tiller of the soil. 


Rueal Depopulation 

Yet in spite of natural tendencies, the British people, 
under the influence of commercial development, have been 
steadily forsaking the fields and flocking into the towns, 
until the depletion of the country-side has become one of 
the great tragedies in our history. In 1861 England and 
Wales had a rural population of 9,105,000 and an urban 
population of approximately 10,961,000 ; in 1914 these 
numbers had become respectively 7,893,000 and 29,068,000. 
In little more than half a century the rural population, 
from being nearly equal to the urban population, has 
become considerably less than one-quarter of the total. 
In Scotland the rural population, after remaining nearly 
stationary from 1901 to 1911, has decreased by 55,000 since 
the latter year, while the population of the burghs has 
increased by 41,000. In Ireland the population has de- 
clined from 5,775,588 in 1862 to 4,381,000 in 1914, mainly 
as a result of emigration from the rural districts. Thus 
we have been losing year by year our healthiest and most 
virile stocks, and have been augmenting the numbers who 
are exposed to the deleterious influence of town life. 

The causes of this decline mainly concern the econo- 
mist. Probably the largest factor has been the attraction 
of higher wages offered by industrialism in towns, while 
insufficient housing accommodation in agricultural districts 
has played an important part; and lack of opportunity 
drives the energetic and adventurous to the plains of 
Australia or the wheat-fields of Canada. We are now 
fully alive to the dangers and disadvantages of depending 
for our food-supply upon foreign countries, and it is uni- 
versally recognised that the future safety and prosperity 
of Britain depends in large measure upon increased de- 
velopment of agriculture, though whether this is to be 
done by some scheme of land nationalisation, the ' single 
tax,' agricultural bounties, duties on imported foods, or 
development of small holdings, is not within the province 
of this book to discuss. The only object here is to rein- 
force the economic arguments by showing that the land 
question is intimately bound up with that of national 


health. It will be of little avail to instruct mothers, or 
build school clinics, or establish schemes of insurance 
unless we recognise this fact both in town and country ; 
and when we have recognised it and have acted upon 
our knowledge, there will be little need for palliative 
measures. In considering proposals for land development 
we must be guided, not only by the return of wealth, but 
by the volume of employment, those measures being most 
beneficial which give occupation to the greatest number. 
Schemes which would not yield a material return for some 
years must necessarily be undertaken by State effort, and 
of these perhaps afforestation is one of the best. Sir 
John Stirling-Maxwell has recently uttered a weighty plea 
for an extensive scheme of this sort, and has pointed out 
that in Great Britain alone there are some sixteen million 
acres of sheep ground and deer forest of which probably 
six millions could be planted. 1 A large scheme of affores- 
tation would provide work under ideal conditions for 
persons suffering from early phthisis, and for many of 
those discharged from sanatoria, who now have no choice 
but to drift back to their old surroundings, where too 
often the disease reasserts itself with fatal effect. To 
measure the value of these schemes solely by economic 
return is seriously to under-estimate their national im- 
portance. Development of agriculture, reclaiming of vast 
areas of marsh and moor in Ireland, and afforestation of 
millions of acres in the Highlands, in addition to benefiting 
health, would offer a varied life to the many thousands of 
the sturdiest stock who now leave our shores every year 
for the Colonies or the United States. 2 

1 The Times, June 19, 20, and 26, 1916. 

2 In his book, Land and Labour in Belgium, Mr. Seebohm Rowntree quotes the 
following remark made by the Chief Inspector of Forests in Belgium : " Ah, you 
English, you always want to know will it pay. In Belgium we look at the matter 
differently. We realise that the afforestation of waste lands affords an enormous 
amount of healthy work for the Belgian people, work required just when otherwise 
the men would be unemployed. We realise the importance of providing a large 
amount of home-grown timber in view of the depletion of the world's timber 
supply ; and we think, too, of the beneficial effects of forests, not only upon climate, 
but on the soil of the waste lands, to the great advantage of the country." 


The Overcrowding of Cities and the Means 
of Relief 

But while much can be done to increase the rural 
population, we are bound to recognise that we must always 
remain chiefly an industrial and town-dwelling people ; for 
the greatest sources of our wealth are industries which 
depend upon our coal-fields and iron-ores, and upon the 
peculiar fitness of the Lancashire climate for cotton- 
spinning. We should certainly be a healthier, and prob- 
ably a happier, people if we became a simple agricultural 
community, but we need not speculate upon the possibility 
of this happening. 

The problem then is to discover the means by which 
we can best render our towns fit for human habitation, 
and the first step is to determine the factor or factors which 
make our great cities so unhealthy. We have fallen into 
the habit of talking vaguely about insanitary surroundings, 
bad housing, insufficient feeding, dirt, and ignorance, forget- 
ful of the fact that all these evils may be rampant in a 
country village whose inhabitants nevertheless display 
remarkable vigour. But we need further investigation 
and much more precise knowledge. On this point the 
views of the writer have already been expressed, viz. that 
pollution of the atmosphere by smoke and dust is now 
by far the largest factor in the causation of preventable 
disease. More might be done directly to prevent these 
evils by better scavenging and greater use of smoke-con- 
suming stoves, but our present methods are quite in- 
adequate. There are some restrictions on emission of 
black smoke, but these are often not enforced ; and, with 
this exception, manufacturers can permit the discharge 
of volumes of brown and yellow smoke and gases, or 
fill the air with clouds of dust to the common detriment 
of the community. Even if the smoke of factories were 
reduced, it would still be necessary to introduce smoke- 
consuming stoves into all the homes of the poor in 
crowded districts, and it is doubtful whether under the 
best circumstances these measures could ever be enforced 
sufficiently widely to secure healthy conditions in large 


But though we may leave undecided the exact cause 
of the unhealthiness of towns, we have now quite suffi- 
cient knowledge to recognise the type of towns which pro- 
vide relatively healthy conditions of life. These are towns 
which, though they may contain populations ranging from 
twenty to forty thousand inhabitants, are essentially of 
a rural character. They have not been cramped in their 
growth, contain no large agglomerations of small streets 
or smoke-flooded areas, and have wide open spaces and 
lines of houses straggling into the surrounding country. 
It is these characteristics which account for the healthiness 
of many of the towns and watering-places in the South of 
England and the suburbs all round London. Many such 
towns exhibit a relatively low death-rate and an infant 
mortality rate below 80 per thousand, which, though 
well above the achievable minimum, represents a vast 
improvement upon the high rates of the industrial cities 
of the North. 

The really serious problem is presented by the manu- 
facturing towns, the great seaports, and the central parts 
of large cities. The congestion of these is not easily realised 
by those who are familiar only with the wealthier and 
better-built parts. Within the London County Council 
area of 116 square miles are crowded together more than 
four and a half millions of persons, one-eighth of the whole 
population of England and Wales, and Dr. Wanklyn, of 
the London County Council, has estimated that more than 
2,365,000 persons are housed in 646,700 tenements of from 
one to four rooms. 1 There are 168 persons to the acre in 
Bethnal Green, 166~ in Shoreditch, 166 in Southwark, 156 
in Stepney, and 144 in Finsbury. On the other hand, all 
round this closely-packed mass of streets there is a wide 
expanse of beautiful country, which is but thinly scattered 
over with villages and towns. The contrast in density of 
population afforded by this area is striking. Taking the 
counties immediately adjacent to London and including 
the County Boroughs and Urban Districts, the density of 
population per acre is 1*4 in Essex, 8*1 in Middlesex, 19 
in Surrey, and l'l in Kent. Both sets of figures are 

1 " Working-Class Home Conditions in London," Proc. Roy. Soc. of Med., 1913. 


based upon the estimated populations in the middle of 
1914. Very similar features are exhibited by Liverpool, 
Glasgow, Belfast, and other great cities and their vicinities. 

A good deal can be done to relieve this congestion by 
increasing the parks and open spaces in cities and forming 
larger playgrounds for children. The clearing of slums is 
also all to the good, though the cost renders extensive 
schemes prohibitive, and it is very doubtful whether the 
policy of re-covering the cleared areas with blocks of 
' model dwellings ' and tenements is really sound. The 
brightly-painted doors and window-frames of these erec- 
tions give an air of cheerfulness to the exterior which is 
an improvement on the wretched houses demolished, but 
the rooms are small, the interiors often lacking in com- 
fort, and the tenants have little in the way of a garden, 
often a stone court being all that is provided for the whole 
block. Moreover, though there may be some decrease 
of chimneys, the great advantage of an open space, from 
which there is no contribution to the general smoke-cloud, 
is lost. We could make better use too of the open spaces 
we actually possess. In many parts of London, and not 
only the wealthy parts, there are squares the use of which 
is restricted to a few of the surrounding inhabitants who 
rarely enter them, while children of the poorer classes 
have nowhere but the neighbouring streets to play in. 
Then there are cemeteries and burial-grounds, through 
some of which paved paths have now been constructed 
and seats placed round ornamental (!) erections of old 
tombstones. Respect for the dead requires that these 
should be treated with reverence, but there need be no 
violation of feeling if the memorials were removed and 
re-erected elsewhere. It would indeed be a great gain if 
all interments within the precincts of cities were forbidden, 
and all cemeteries and burial-grounds within the boundaries 
acquired as public open spaces, thus relieving, in one 
direction at least, the pressure of the dead hand upon the 

Much more important however is it to develop the 
policy of taking people right out of the crowded districts 
and scattering the towns, so to speak, over a much wider 


area of country. There is no longer any need for people 
to live together in dense masses. Our towns were built 
for bygone conditions, when the science of road-making 
was unknown and travelling was slow. But the rapid 
growth of railway, motor, and electric transport has now 
made our finest cities anachronisms ; and our models for 
the future need no longer be vast cities like Glasgow, with 
its great docks and its infant mortality rate of 133 ; 
Liverpool, with its stately Municipal Buildings and its 1600 
deaths a year from tuberculosis ; or Dublin, with its Vice- 
Kegal Castle, its Trinity College, and its 20,000 families 
in single -room tenements ; but such places as Letchworth 
and East Ham, where, though the mansions of the rich 
are not numerous, the masses of the poor live under 
healthy conditions. As Walt Whitman says : — 

The place where a great city stands is not the place of stretch'd wharves, 

docks, manufactures, deposits of produce merely, 
Nor the place of ceaseless salutes of new-comers or the anchor-lifters 

of the departing, 
Nor the place of the tallest and costliest buildings or shops selling goods 

from the rest of the earth, 
Nor the place of the best libraries and schools, nor the place where 

money is plentiest, 
Nor the place of the most numerous population. 

Where the city of the healthiest fathers stands, 
Where the city of the best-bodied mothers stands, 
There the great city stands. 

The scattering of a city over a wider area demands 
broader roads, increased means of transit, and termination 
of the vicious system of holding up land in suburbs for 
higher rent. In many industrial towns of moderate size 
these measures would enable the workers to live outside, 
and come in daily to their work without undue travelling 
or expense, but in the largest cities we cannot remove the 
people unless we remove their work as well. It is pitiful 
to witness the crowds of tired workers struggling for even 
standing room in 'bus, tram, or train in many parts of 
London at the end of the day ; and in wet weather the 
conditions are simply deplorable. To spend perhaps two 
hours every day travelling in an overcrowded vehicle is a 
heavy price to pay for a few hours of purer air at night. 


But the way out of this impasse has already been shown. 
At Letchworth in Hertfordshire there has been carried 
out within the last twelve years perhaps the most success- 
ful and instructive social experiment of recent times. A 
large area of land was purchased by a limited liability 
company to be developed as a building estate. The enter- 
prise however is not a commercial venture in the ordinary 
sense of the word, since 5 per cent is the maximum rate of 
interest which can be paid on its capital, any remaining 
profits being devoted to improvement of the estate. 
Houses have been built for all classes and factories estab- 
lished, the latter being one of the distinguishing features 
of the movement. We are familiar with attractively- 
built districts, whether called ' garden-suburbs ' or not, 
which are springing up all round London, but these provide 
residences mainly for the wealthier classes, and factories 
in them are discouraged. Letchworth is distinguished 
by its policy of actually inviting manufacturers to move 
into its area, thus affording numbers of the working classes 
opportunities to earn their living within easy reach of 
their dwellings under the most healthy conditions. The 
population of Letchworth, which is rapidly growing, is 
now about 12,000, but it is not to be allowed to exceed 
30,000, while large areas have been marked off which are 
never to be built upon. 

Segregation of Factories 

Yet another lesson can be learnt from Letchworth. 
The factories there are limited to special districts which 
are separated from the workers' cottages. This is a principle 
which could be widely extended. Until the passing of the 
Town Planning Acts practically no attempt was made to 
separate factories from residences, except in the districts 
occupied by the wealthier classes, with the result that 
each factory has tended to become the centre of a little 
community which is aroused in the early morning by the 
shriek of its syren, and lives under the smoke of its 
chimneys throughout the year. The Town Planning Acts 
enable Local Authorities to define certain areas for the 


erection of factories, but it will be many years before we 
can substantially alter conditions in our large towns, 
sweep away our hideous slums, and dot the country round 
London and other great cities with Letchworths. Never- 
theless a beginning has been made, and the interests of 
national health demand that further efforts should be 
pushed on with all vigour. Meanwhile, in the towns we 
could endeavour to undo or avoid some of the mistakes 
of the past. We need not continue to build schools in 
close proximity to gas-works or in main thoroughfares, 
where double windows are necessary to keep out the noise 
and incidentally such fresh air as there may be ; we need 
not establish our hospitals and manure-strewn railway 
sidings within a few yards of each other ; and we need not 
permit the odours from a pickle factory or a brewery to 
disseminate themselves through the principal shopping 
thoroughfares of the metropolis. 

Bad Housing 

Bad housing is believed to be a fruitful cause of ill- 
health, and many Acts have been passed in recent years 
intended to improve the homes of the working classes. 
The deplorable housing condition of many of the poorer 
classes both in town and country has been ably described 
by Geddes, Savage, Booth, Rowntree, and others, as well 
as in the annual reports of the Local Government Board 
and the reports of many Medical Officers of Health. Two 
evils are usually combined, viz. crowding together of too 
many houses, and bad or dilapidated structure of the 
houses. For the moment we will examine only the latter, 
leaving for separate consideration the evil of overcrowding 
of houses ; and we are concerned simply with the effects of 
bad housing on health independently of discomfort, de- 
moralisation, and other evils which it causes. 

It will simplify the investigation if we note that defects 
in housing may be divided broadly into two main groups, 
viz. (1) defects in the sanitary systems, i.e. the arrange- 
ments for the supply of water and for the removal of waste 
material, excreta, etc. ; and (2) structural defects, such as 


damp walls, leaky roofs, broken floors, low ceilings, and 
general dilapidation. 

Defects belonging to the first group are far more im- 
portant as a cause of ill-health than those of the second. 
A pure water-supply is one of the first conditions of health, 
and we know that if the drinking water is inefficiently 
filtered, or becomes polluted owing to faults in the service 
allowing access of sewage to it, grave epidemics may 
result. Now, speaking generally, the water supplied to 
all classes of the community in this country is pure. It 
is true that the supply is often deficient in quantity in poor 
neighbourhoods, and that the provision of water-taps and 
baths is frequently inadequate, with the result that cleanli- 
ness is sometimes next to impossible, but on the ground 
of impurity there is little scope for complaint. We can 
speak with assurance on this point, for we know that 
certain diseases, particularly typhoid fever, are mainly 
conveyed by water, and the low rate of incidence to which 
these diseases have now been reduced is proof of the 
general excellence of our water-service. This real and 
great achievement in Public Health has only been rendered 
possible by municipal control over the water-services, the 
municipality either providing the supply itself, or exer- 
cising supervision over private companies by means of 
statutory powers and sanitary inspection. The advantage 
of a pure water-supply is shared by all districts, and in 
condemning bad housing we must remember that in one 
exceedingly important respect the humblest home is now 
in a better position than was many a great and even 
royal mansion half a century ago. 

The sanitary arrangements for the removal of waste 
water and excreta are also, generally speaking, good. Local 
Authorities now exercise a very considerable degree of 
control over these services, and they require many pre- 
cautions in the nature of trapping, flushing, and soundness 
of structure of drains, sinks, and water-closets to be 
observed. In the North of England the sanitary systems 
are not on the whole as satisfactory as those in the South, 
insanitary ash-pits still being in considerable use. Rapid 
progress is however being made in the conversion of ash- 



pits, and it may be anticipated that before long, efficient 
systems will have been generally established in their 

We may include also, as a sanitary requirement, 
properly constructed and covered dustbins for household 
refuse. If these are allowed to become foul they are un- 
doubtedly a cause of ill-health, but the prevention of 
nuisance arising from them is not so much a question of 
housing as of frequent removal of contents by municipal 

The fact is that the great bulk of defects which sani- 
tary authorities discover and require to be remedied are 
structural defects in walls, floors, and roofs. When a 
house is so dilapidated that it is considered unfit for 
human habitation the Local Authority, after somewhat 
complex procedure, can issue a closing or a demolition 
order, but the number of houses closed or demolished is 
small in comparison with the number of those in which 
defects are remedied. The following list from the report 
of the Medical Officer of Health of a large industrial town 
in Yorkshire illustrates the type of defects which are most 
frequently detected by house-to-house inspection : — 

Foul walls around house sinks 

Sinks defective or foul 

Houses requiring general repairs . 

House roofs defective 

Eaves spouts or down spouts defective 

Defective plaster on walls and ceilings 

Defective ash-pit doors 

Dirty houses or parts thereof 

Damp houses 

General repairs to water-closets . 

Windows not made to open 

Houses without sinks 

Choked drains 

Filthy water-closet apartments . 

Other defects 



Tables of this sort look imposing, but those who study 
without bias this particular town, or any similar town, 
with its squalid and sunless courts, its noisy and narrow 


streets filled with children, its dense population, and its 
infant mortality running up in some districts to nearly 
200 per thousand births, will soon realise that the whole 
of these efforts amounts to little more than superficial 
tinkering. It is of course easier to deal with this aspect 
of the housing problem than with clearance of areas necessi- 
tating heavy expenditure and interference with vested 
interests, which the average Local Authority hesitates to 
undertake. Thus an appearance of activity is created 
which suggests that far more is being done to improve 
conditions than is actually the case. " Progress has been 
made with the Town Planning Acts mainly in the direction 
of remedying defects," is a statement which appears in 
the report of the Medical Officer of Health of a large city 
in a northern county, and is typical of many reports on 

But defective housing by itself is probably only a minor 
cause of ill-health. It is only when the houses are aggre- 
gated in large masses that the worst effects arise, and then 
the evil is due not nearly so much to the defectiveness of 
the houses as to the overcrowding both of occupants per 
room and of houses per acre. If we could take out a 
patch of, say, fifty acres from the most crowded and worst- 
built district of London, Liverpool, or Dublin and set it 
down precisely as it is among the pines of Surrey, or on 
the wind-swept moors of Yorkshire, the probability is 
that the improvement in the health of the inhabitants 
would be enormous. There are in fact patches of bad 
housing in many country towns and villages presenting 
the worst features of slums whose occupants, nevertheless, 
exhibit a high degree of healthiness. The agricultural 
labourer forms the healthiest class of manual workers, yet 
his bad housing is notorious ; and the wretchedly-housed 
peasants of Connaught, the Highlands, and many parts of 
rural England exhibit the lowest rates of infant mortality 
to be found in the kingdom. Sir John Gorst says : "I 
" have seen magnificent children living in hovels condemned 
" as unfit for human habitation in the West of Ireland, 
" models of health and vigour. The explanation was that 
" they lived almost entirely in the open air. The children 



" of gipsies and vagrants who live in tents on commons, 
" though filthy and untaught, are far healthier in their free, 
" open-air surroundings than the corresponding class in the 
" slums of the city." 1 Medical Officers of Health have called 
attention to the same fact. Dr. Lyster, the M.O.H. for 
Hampshire, for instance, says : " This [bad housing] is 
" one of the less important factors in the production of a 
" high infant mortality, or in the causation of consumption. 
". . . The modern requirements as regards housing cannot 
" be regarded as belonging to the essentials for a healthy 
" existence, such as food for instance ; and we shall only be 
" endangering our cause by making ill-founded claims of 
" this kind." 2 

On many grounds improvement of the wretched homes 
of the poor is an urgent social duty, but do not let us 
conclude that the mere remedying of structural defects 
is going to have an appreciable influence in lessening the 
unhealthiness of cities. 

The Difficulties of Clearing Slum Areas 

Clearing of slum districts being then of far greater 
importance than patching of walls, it may be worth while 
to examine more closely some of the difficulties which 
hinder widespread adoption of this policy. These are 
mainly the necessity of recouping part of the expenditure, 
and the rehousing of the displaced population (or an 
equivalent number of other persons) partly on the cleared 
area and partly elsewhere. 

The cost of clearance schemes in towns is so great that 
Local Authorities cannot afford simply to lay out an area 
as an open space, but find themselves obliged to recover 
some of their expenditure by re-erecting, on part of the 
land at least, tenements and shops from which they derive 
rents and rates. This is a purely economic question with 
which we are not here concerned, beyond pointing out 
that in so far as the cost is due to purchase of land it is 
part and parcel of the larger question which we have seen 
is so intimately associated with Public Health. We may 

1 The Children of the Nation, 1906. 
2 " Housing Problems in County Areas," Jour. Roy. San. Inst., 1912. 


note however that the difficulty affords an example of 
the way in which a Local Authority may be pulled in differ- 
ent directions by different motives, as a result of giving it 
diverse functions to perform. One and the same body is 
continually urged to keep down the rates, and at the same 
time is expected to find large sums of money for the ad- 
vancement of Public Health. It is for reasons of this 
kind that the writer has urged in a later chapter that 
Public Health administration should be separated from 
other forms of municipal activity. 

The necessity of rehousing some of the displaced popula- 
tion arises from the fact that many of these persons are 
bound to remain near the scene of their daily work. But 
if the principle, in operation at Letchworth, of moving 
factories and industries out of towns were more widely 
adopted, this hindrance to clearing congested areas would 
become progressively less. 

The Cost of Building 

We have still to consider the obstacle to rehousing 
which arises from cost of building apart from that of land. 
The cost of building is proportionately much greater in 
rural than in urban areas, for in the latter the tenement 
system enables a number of families to be housed under 
one roof on a small piece of land. In the country it is 
usually necessary to build separate cottages, and the low 
rents obtainable do not make it profitable for landlords 
to erect even the cheapest cottages if they are to conform 
to modern requirements. 

But the view may be put forward that we have culti- 
vated an unnecessarily elaborate idea of the dwellings 
which human beings require for a healthy and comfortable 
life. We are so saturated with the belief that health 
depends upon housing that we have created a whole 
series of building laws and by-laws relating both to 
material and construction from foundation to roof ; and 
we do not regard a person as properly housed unless he 
lives in a structure of bricks and mortar, with white- 
washed plaster ceilings, papered walls, and the latest 


sanitary appliances. Yet, in rural districts at all events, 
a far simpler and less costly structure would be equally 
healthy and equally comfortable, and even the sanitary 
arrangements may be of a primitive character provided the 
water - supply is free from risk of contamination. The 
backwoodsman in America builds his hut of logs or planks, 
and the Scottish crofter and the Irish peasant live in the 
humblest of habitations. During recent years a move- 
ment has grown among the wealthier classes of spending 
the summer months in buildings of a very simple character. 
' Bungalow ' towns have sprung up along the south coast, 
and some of the structures in these are merely old con- 
verted railway carriages. Many of the bungalows up the 
river which are occupied for months together are really 
only elaborate and ornamented sheds. 

The importance of taking masses of the people out of 
the purlieus of cities is so great that it seems mere foolish- 
ness to impede the process by clinging to a notion that 
human beings must live within bricks and mortar. During 
the last two years many lessons have been learnt in 
the rapid construction of ' huts ' for soldiers, and these 
can be rendered quite comfortable and cheerful. Some 
of the temporary hospitals are simple erections of wood 
or corrugated iron, built on short piles of bricks so as to 
avoid cost of foundations, and these have proved quite 
satisfactory for wounded men. We cannot create a Letch- 
worth in a day, but Local Authorities could rapidly 
establish ' bungalow ' towns, with schools, playing-fields, 
etc. attached, in the country districts all round large 
cities. 1 It might be argued that such quarters would not 

1 Mrs. Francis Acland has given the following description of ' Elisabeth- 
dorp,' a village constructed in Holland for the benefit of interned Belgian soldiers 
and their families : " When I visited the place in December 1915, it consisted of 
ten houses only ; this summer, on my second visit, I found a thriving village with 
over eight hundred inhabitants. There are some hundred houses, extensive 
carpenters' shops for the men, work-rooms for the women, schools and a creche 
for the children ; a prosperous vegetable garden ; a village bakery and restaurant ; 
a well-equipped hospital. Every building is movable, and immediately after the 
War will be transported into Belgium. The houses are four-roomed, each family 
having two rooms ; they are bunt on a strong wooden framework, covered with 
weather-boarding, and roofed with asbestos tiling, the whole designed so as to take 
to pieces for transport. Gaily painted, and with flower-boxes at the windows, 
they present, thanks to the care and pride of their Belgian tenants, a most attractive 
appearance. Each house, complete with furniture, costs from £100 to £105." — 
Daily News, August 16, 1916. 


be suitable for winter, but they can as a matter of fact be 
made quite comfortable. Those who would oppose them 
on this ground should reflect again upon me wretched con- 
ditions of life in crowded areas which they are intended 
to replace. A bungalow may not make an ideal home, 
but at least it is preferable to a tenement in a slum. Again 
let us recall that only yesterday man was a primitive 
savage wandering freely over the land, and even to-day — 
if health were the only consideration — something but 
little better than a fox-hole would suffice for his home. 
We cannot provide marble staircases, pictures, and 
tapestries for the masses, and perhaps after all these only 
minister to an artificial sense of comfort, but we can secure 
to them good health, and that with a very considerable 
degree of comfort. 1 

' Summer Camps ' 

A modification of the above proposals which might be 
tested at even less cost, is the opening by municipal 
authorities of ' summer camps ' in the vicinity of towns. 
These could be largely constructed of canvas, sites and 
tents being let for small weekly rents. We know that 
parties of boys often camp out for weeks together in the 
summer months with great benefit to their health, and the 
camps would enable many a working man and lad living 
as lodgers to get away to fresher air after their day's labour. 

1 In connection with these proposals the following paragraph from the report 
of the chief medical officer to the Board of Education for 1915 may be quoted : 
" One successful and interesting experiment during the year, in the provision, at 
a minimum cost, of classrooms of an open-air type in connection with a school for 
mentally defective children, is worthy of notice. In the autumn of 1915 arrange- 
ments were made for the accommodation of boys from the Usher Street and Grange 
Road Schools at Bradford for mentally defective children, in the grounds attached 
to the Margaret McMillan School at Thackley. At first the boys' school was 
conducted as a Camp School under canvas, but on the approach of winter it was 
decided to erect wooden huts, and these have been constructed by the boys them- 
selves. A number of separate classrooms have been provided with windows on 
three sides, all of which can be opened if desired. The construction has been 
reduced to the simplest ; no artisan labour has been employed. One of the class- 
rooms was in constant use during the erection of these huts as a woodwork room in 
which about fifteen of the boys were kept busy making parts of the new rooms. 
Other boys laid out the garden allotted to the school. The whole enterprise is 
most creditable and affords a valuable lesson in self-help on the part both of 
the Authority and the scholars themselves which should not be allowed to pass 


They would also afford an opportunity for poor working- 
class families to obtain a cheap holiday during the hot 
weather when epidemic diarrhoea is at its worst among 
children in towns. The annual exodus of hop-pickers 
from the East End of London shows how eagerly any 
opportunity is grasped by the workers of getting into the 
country at little cost. If too we are led to adopt some 
system of national physical training for boys and youths, 
it might well take the form of requiring them to spend 
three months of each year, say from the age of fourteen to 
seventeen, in camp. Our education authorities have in the 
opinion of the writer devoted too much attention to mental 
development of children and far too little to physical train- 
ing. If our schools were provided with adequate play- 
grounds, the writer would urge that afternoon school should 
be abolished for children under twelve and the time spent 
in games in the open air. Possibly the soundest educational 
movement of recent times, using the words in their broadest 
sense, is the boy-scout movement, and this we owe not to 
an educationalist but to a soldier. 

Sleeping Out 

Incidentally too, we might abolish our absurd laws 
against sleeping out. Sleeping in the open air is natural 
and beneficial to mankind. During the War we have heard 
many accounts of the improved health of the erstwhile 
city worker, who, often for the first time, has lived under 
something approaching natural conditions. In New York, 
during spells of hot weather, thousands of persons are 
permitted to sleep in the parks and on the neighbouring 
sea beaches. But in this country if a man has " no visible 
means of subsistence," and has therefore a double motive 
for sleeping out, we can put him in prison for so doing. 
Yet being destitute he is probably in a state of health 
which makes sleeping in the open air the best thing for him. 
It is obviously undesirable to permit people to sleep pro- 
miscuously in the streets, but there is no adequate reason 
why the parks in London and other large cities should not 
be open all night, and homeless persons not only not pro- 


hibited but actually encouraged to sleep in them. During 
the summer months at all events they would be better 
off than in the casual wards. Those who consider that 
observance of conventional morality is more important 
than health, will object to this proposal on the ground 
that it would afford opportunity for unseemly behaviour. 
But assuming that this is a real risk, the closing of the 
parks does not prevent it, but merely drives it elsewhere, 
satisfying, nevertheless, that type of mind which believes 
that if an evil is hidden it no longer exists. 

We have now examined the main environmental factors 
in the causation of disease, and we have seen that the land 
question lies at the bottom of nearly all the forces which 
make for ill-health, whether they be rural depopulation, 
holding up of suburban land, continuance of slums, or in- 
sufficient housing, for the question also enters into this, 
through the cost of building materials. Curative and 
palliative measures alone will never secure a healthy 
population. We may multiply Medical Officers of Health, 
sanitary inspectors, and health visitors, and we may 
establish insurance systems and medical services of all 
sorts, but unless we deal with the great environmental 
causes which in large cities are continually producing 
disease in our midst, we shall still lose our thousands of 
infants every year, we shall still have our defective school 
population, and we shall still be ravaged by tuberculosis 
and other preventable diseases. The majority of the 
people in these islands — by nature a freely-roaming species 
— are landless in the country for which they fight and 
whose wealth they create. Whether the ultimate solution 
of this great problem is to be found in national purchase 
or in progressive taxation or otherwise, the words are as 
true to-day as when they were first spoken that " the only 
way to get the people back to the land is to get the land 
back to the people." 



The meaning of ' medical treatment ' — The growth and importance of 
institutional treatment — The insufficiency of institutional treatment — 
Medical treatment by general practitioners — The size of working-class 
practices — ' Lightning ' diagnosis — The absence of expert assistance 
— Diagnosis in general practice — The lack of laboratories for expert 
diagnosis — The futility of treatment in a bad environment — The dis- 
content with the panel system — Medical treatment of school children 
— Mortality in child-bed and its causes — Skilled attendance in child-bed 
— The pathological causes of deaths in child-bed : puerperal fever — 
General practitioner or midwife ? — Attendance in confinement and in- 
fant mortality — Maternity benefit — The question of a public maternity 
service — Medical treatment and Public Health. 

The Meaning of ' Medical Treatment ' 

We will turn now from consideration of the causes of 
disease and examine the facilities available among the 
working classes for medical treatment. It is necessary 
however, as a preliminary step, to determine the mean- 
ing which should be attached to the words ' medical treat- 
ment,' and the services which should be included, in the 
light of modern knowledge relating to the cure of disease. 
The history of medicine shows that methods for heal- 
ing the sick have passed broadly through three stages. 
The first was the era of superstition, during which diseases 
were believed to be the work of evil spirits ; and charms, 
rites, and incantations were employed to drive them out of 
those afflicted. The grosser elements of superstition in 
this form of treatment have disappeared, but ' Christian 
Science ' and ' Faith Healing ' still indicate belief in 
mystic powers to cure disease. The second stage was 
marked by the change from belief in magic to belief in 
medicaments. Evil spirits were succeeded by ' humours,' 
and the efforts of doctors were directed towards controlling 



these or expelling them from the body. The whole animal, 
vegetable, and mineral world was ransacked to discover 
new drugs, and we need not go back very many years to 
find such extraordinary things as unicorn's horn, newts' 
tongues, and frog's blood being prescribed. There was 
little scientific knowledge of the mode of action of drugs, 
and the prescriptions were usually of a blunderbuss char- 
acter, containing many ingredients in the hope that if 
one failed another might succeed. This stage has indeed 
not yet passed. The laity have a widespread belief in 
the all-sufficiency of drugs, ' tonics,' etc., which leads to 
an enormous amount of self -medication and to the prodi- 
gious sale of patent and proprietary remedies, the vendors 
of which laud their wares as ' purifiers ' of the blood, 
while ' uric acid ' replaces the ' humours ' of earlier 
centuries. The importance still attached to drugs was 
exemplified in the Insurance Act, under which two out of 
every nine shillings provided for medical benefit was 
allocated to the purchase of medicines. Circumstances 
compel doctors to give a more or less tacit assent to the 
belief in the efficacy of drugs, though Sir Samuel Wilks is 
credited with having said that half a dozen drugs would 
do all that is possible in medicine by the administration 
of medicaments. Without rigidly hmiting them to this 
minimum, it is probable that most doctors would be satis- 
fied with a mere handful of drugs out of the many thou- 
sands which are contained in the Pharmacopoeia and 

The third and modern stage of medical treatment is 
based upon scientific study of disease and of the human 
body. Exact diagnosis of the malady is the first step, and 
efforts are then made to cure it which bear, as far as pos- 
sible, distinct relation to its cause. For these purposes 
medicine no longer blindly administers nauseous com- 
pounds, but calls to its aid physiology, anatomy, chemistry, 
physics, and other sciences, and at the same time studies 
the constitution of the patient and his surroundings, in- 
cluding in its treatment suitable dieting, care, nursing, 
and hygienic conditions. Let us consider what the full 
medical treatment of a serious case of illness may involve. 


For the purpose of diagnosis it may be necessary to 
employ X-rays, or make a bacteriological examination 
of the sputum, or a microscopic investigation of a new 
growth, all methods demanding the highest technical skill 
•and elaborate apparatus. If the patient is admitted to a 
hospital he is placed under the charge of the physician 
or surgeon who at first seems most appropriate, but 
during the course of the illness it may be found necessary to 
transfer him to a ward for special diseases. If an operation 
is contemplated, consultations may be held between the 
physician and surgeon, and either may obtain a special 
opinion from the oculist or aurist upon some exceptional 
condition of the eyes or ears. The advice of the gynaecolo- 
gist may be sought for a woman. Before the operation 
is undertaken the dentist may be asked to correct faulty 
condition of the teeth. During the operation the surgeon 
has the assistance of an anaesthetist, his house-surgeon, and 
a staff of sisters and nurses, and he may ask any of his 
colleagues to be present and advise him if necessary. 
During convalescence the patient may receive various 
forms of special treatment, such as massage or electrical 
treatment. Finally the instrument-maker may be required 
under the supervision of the surgeon to fit him with arti- 
ficial supports, etc. This procedure, involving as it does 
co-operation between specialists of the most diverse 
character, is the only one which can be regarded as 
providing medical treatment in consonance with modern 

The growth of medicine during the last half-century 
has also profoundly affected the medical profession. The 
volume of knowledge is now so vast that it is far beyond 
the capacity of even the ablest man to master the whole. 
Hence specialism has arisen in all directions. Physicians 
and surgeons were early separated, but the process has 
now been carried much further. Physicians specialise in 
diseases of the heart, the lungs, the nervous system, or the 
digestive system, in children's diseases, mental diseases, 
diseases of the skin, and tropical diseases. Even a single 
affection may form a domain by itself, such as tuberculosis, 
venereal diseases, or gout. Surgeons devote themselves 


to the surgery of the throat, nose, and ear, the eye, the 
brain, the abdomen, the excretory system, the generative 
system, or the muscles and limbs. Gynaecologists concern 
themselves with conditions peculiar to women. In quite 
recent years diagnosis and treatment by X-rays, light 
rays, electricity, and radium have called into being a new 
class of specialists who devote themselves to these methods. 
Besides the clinicians, there are pathologists and bacterio- 
logists who, although they may never see the patient, may 
be directly responsible for the methods adopted to treat 
him, as a result of their reports on the excretions, the blood, 
morbid growths, or micro-organisms. 

It is quite clear that for all but the wealthy classes, 
medical treatment of this character can only be provided 
through hospitals and institutions. The poor cannot afford 
to pay the fees of specialists, their homes are not suited for 
proper care and nursing during serious illness, and facilities 
for elaborate methods of diagnosis are inadequate. In 
the middle classes the problem has been partially solved by 
the establishment of nursing homes, but even with this 
advantage it is doubtful whether, on the whole, the medical 
treatment received by these classes is as thorough as that 
provided for the poor at a large hospital. Medical treat- 
ment for serious illness to-day necessarily involves treat- 
ment at an institution in which all modern methods are 
available, if any real meaning is to be attached to the 

This conception of medical treatment appears to find 
no place for the general practitioner, but so far from this 
being the case, his functions are in some respects the 
most important of those performed by medical men. His 
primary duty is, or should be, that of diagnosis. Unless 
the patient goes straight to a hospital, the general practi- 
tioner is the first to see the sick person, and upon his 
correct reading of the complaint may depend the whole 
future course and treatment of the case. If it is a trivial 
affection he can treat it himself, if it is a serious disease he 
should be able to indicate the appropriate institution or 
form of special treatment most likely to ensure recovery. 
Error in diagnosis may be disastrous. If a general prac- 


titioner regards a case of cancer of the stomach as ' dys- 
pepsia,' strangulated hernia as ' colic,' enteric tever as 
diarrhoea, diphtheria as sore throat, or early phthisis as 
a simple cough — mistakes which have all been made with 
regrettable frequency, — the opportunity of effecting a cure 
may have been irretrievably lost by the time the error is 
discovered. The general practitioner should himself there- 
fore be a specialist — a specialist in diagnosis, — and to aid 
him in this work he should have every facility in the way 
of laboratories for bacteriological and pathological ex- 
aminations. It is sheer impossibility for a general practi- 
tioner to apply all modern methods of treatment or even to 
keep himself up to date with new discoveries in treatment ; 
but if he performs the first step of diagnosis efficiently he 
becomes the channel through which patients suffering 
from serious illness find their way to hospital, where they 
can receive the best treatment. 

Division of function and co-operation in a scheme in 
which every one plays a skilled and useful part is in fact 
the essential characteristic of modern medicine ; and a 
system of medical attendance which consists simply in 
providing the services of a general practitioner is no more 
an adequate service than would be a postal service con- 
sisting of sorters without postmasters, clerks, telegraphists, 
and telephonists. 

We have now sketched out the division of function 
among medical men to which growth of knowledge has 
inevitably led ; and we have next to consider how far an 
organised scheme is in actual operation among the work- 
ing classes, beginning with the provision for institutional 

The Growth and Importance of Institutional 

The most striking fact about institutional treatment 
is its remarkable growth during the last forty years or so. 
We cannot measure this directly by the number of patients 
treated, since no complete record is even now compiled, 
but we can gain a very fair idea from the number of deaths 



which occur in institutions and are stated in the Annual 
Reports of the Registrar-General. The following table 
shows the deaths in institutions in England and Wales for 
the years 1870 and 1914 :— 

Deaths in Public Institutions 


Percentage of Total Deaths. 



Workhouses and Workhouse Infirmaries 
Lunatic Asylums 








We see from this table that in forty-four years the 
percentage of deaths in institutions has increased by nearly 
threefold, and that now more than one-fifth of all the 
deaths in England and Wales occur in public institutions. 
A better idea of the extent to which institutions are used 
can however be gained by comparing their distribution in 
different types of area. The following table shows the 
distribution according to place of occurrence of the 516,742 
deaths which occurred in England and Wales in 1914 : — 

Deaths according to Place op Occurrence 



County Boroughs 
Other Urban Districts 
Eural Districts . 

Deaths in Public 


Deaths in Other 



It will be noticed that in London not far short of half 
the total deaths occur in public institutions, and of these 
rather more than half are in Poor Law institutions. In the 
County Boroughs the proportion is rather less than 25 per 
cent of the total. In the smaller Urban Districts and in 
the Rural Districts the percentage is very much less, but 
in gauging the usefulness of institutions it must be remem- 


bered that the need for them is appreciably smaller in 
rural areas than in towns, since the amount of prevent- 
able disease is much less, and the proportion of deaths 
from senile conditions for which medical treatment can 
do but little, is greater. Moreover, a considerable propor- 
tion of the cases which would benefit by hospital treatment 
come into the towns to receive it. 

We can supplement these figures by certain additional 
facts. In the hospitals of the Metropolitan Asylums Board 
for infectious diseases, the proportion of patients actually 
admitted to those legally admissible has grown from 33 '6 
per cent in 1890 to 87"5 per cent in 1914, and the percentage 
of admissions is as high in good-class as in poor-class 
neighbourhoods, which shows that little prejudice exists 
against accepting free State assistance during illness from 
these diseases. Institutions are now provided by public 
authorities for the treatment of ringworm, ophthalmia, 
epilepsy, and mental diseases ; while under the Insurance 
Act sanatoria for those suffering from tuberculosis are 
now being established in many parts of the country. These 
statements refer only to in-patients, but several millions 
of out-patients must be added to the number of those who 
receive treatment through hospitals. Education author- 
ities are making arrangements with hospitals for the 
treatment as out-patients of large numbers of school 
children, and quite recently the Government has indicated 
its intention of providing treatment through hospitals for 
those suffering from venereal disease. 

When we reflect upon the vast numbers of persons who 
either as in-patients or out-patients pass through the doors 
of our institutions, upon the fact that practically all 
serious operations among the working classes must be 
performed in hospitals, and that large numbers of persons 
suffering from chronic ailments are maintained permanently 
in infirmaries, it becomes quite evident that the hospitals 
and kindred institutions form the real backbone of medical 
treatment in this country. The general practitioners may 
see a larger number of patients during the year, but it is 
certain that the hospitals do the great bulk of all the more 
serious work among the working classes. 


A process of evolution has in fact been driving the 
general practitioner into the place naturally indicated for 
him in an organised scheme, that of diagnostician, and has 
steadily reduced the volume of treatment left to him to 
perform. Thirty years ago an average case of scarlet 
fever or diphtheria probably meant several weeks' attend- 
ance by the doctor and the earning of substantial fees ; 
to-day as soon as he diagnoses the case it is removed to 
the fever hospital. In many other ways the growth of 
institutional treatment has been eating into his practice, 
while the tuberculosis officer, the school doctor, and the 
registered midwife have deprived him of part of his work 
in other directions. The decline of general practice was 
in the very nature of things inevitable, and although the 
Insurance Act, by the importance it has assigned to medical 
treatment by general practitioners, has tried to reverse 
the evolutionary process, it is not likely to have any per- 
manent effect upon the strong tendency towards specialism 
and institutional treatment. 

But there is much need for these facts to be realised 
by legislators. To speak of ' adequate ' medical treat- 
ment in an Act of Parliament, and to mean thereby treat- 
ment by a general practitioner, is, without in any way 
reflecting upon the practitioner, simply to play with 
words. And in the debates on the Insurance Act no one 
seems to have realised that adequate medical attendance 
for all serious affections means hospital attendance both 
in theory and in fact. It was not even until two 
years after the Act had been passed that the Govern- 
ment, for the first time, made a census of hospital beds in 
this country, after the necessity had been shown by the 
Fabian Society. Yet had it not been for the voluntary 
hospitals, medical benefit under the Insurance Act would 
have been a farce. 

The Insufficiency of Institutional Treatment 

But great though the growth of institutional treatment 
has been, it has not kept pace with the continually-increasing 
demands of the community, and nearly all large hospitals 


have long lists of applicants waiting for admission, most of 
the cases being in need of surgical treatment. To quote 
some examples : in 1914 the Western Infirmary in Glasgow, 
with about 600 beds, had a waiting list of between 700 and 
800, 1 and the Royal Victoria Infirmary had a similar list 
of 1300. 2 The Insurance Act has demonstrated the need 
of further hospital accommodation, the immediate effect 
of medical benefit being a much greater demand on the 
in-patient space of nearly all the hospitals. This was 
the result of an Act which applied to only one-third of the 
population, and that the healthiest third, since it consists 
of people capable of work and mainly of men. Had the 
Act applied to women and children and the class of casual 
labourers, it is reasonable to suppose that the increase in 
the demand for beds would have been very considerably 
greater. This means that many thousands of women and 
children are not getting the hospital treatment which a 
simple sorting out by panel doctors would show them to 
require. It is estimated that about 50 per cent of the 
in-patients in the hospitals of the United Kingdom are 
insured persons. That is, one-half of the accommodation 
is devoted to one-third of the populace who happen to be 
under better conditions for having their maladies detected. 
The Fabian Society has the credit of having made the 
first complete survey of hospital accommodation in this 
country. In their report, published in 1914, they esti- 
mated the need for hospital beds at between 2 and 4 
per thousand of the population, exclusive of provision for 
tuberculosis and other notifiable diseases. In Germany 
provision is made for 5 per thousand in towns and 3 per 
thousand in the country ; in France the minimum is 2 per 
thousand. In England, according to the report, in not 
one county does the number of hospital beds reach the 
standard of 2 per thousand of the population, while in 
many it falls below 1 per thousand. A rough estimate 
made by the Local Government Board at a later date 
showed about 1 3 hospital beds per thousand of the popula- 
tion in England and Wales, or-L7 including institutions 
for convalescence. As in the Fabian Society's estimate, 

1 Hospital, December 1914. 2 Hospital, June 1914. 


hospitals for infectious diseases and Poor Law infirmaries 
are excluded. If we examine special institutions, for 
example sanatoria for tuberculosis, we find the same 
story of deficiency. 

From these figures it would appear that at least another 
17,000 beds are required in England and Wales to bring 
the proportion up even to the minimum of 2 per thousand 
of the population. It is important to notice however 
that the deficiency is by no means equally distributed. 
The table given on p. 173 shows that the County Boroughs 
as a whole are far less well supplied than London, and 
experience shows that even London cannot be regarded as 
overprovicled. It is true that the London hospitals draw 
some of their inmates from outside the county area, but 
this is also true of other large towns. The underprovision 
in rural districts is not so serious having regard to the 
smaller demand. It is in the large industrial and mining 
towns, the very places where sickness is greatest and 
hospital treatment most needed, that the really grave 
deficiency exists. 

Medical Treatment by General Practitioners 

Medical treatment, otherwise than through hospitals, 
is given among the working classes by private practice, 
panel practice, clubs, medical institutes, dispensaries, and 
outdoor medical relief. In addition a great deal of medical 
treatment of a land is given by herbalists, bone-setters, 
chemists, and other unqualified practitioners. In their 
essentials these systems do not differ very much from each 
other. They all provide practically the same treatment 
for the same class of patients under the same disadvan- 
tages and difficulties. Club practice has been as roundly 
condemned by doctors as by any other persons ; private 
practice in districts where the fees range from 6d. to 2s. for 
advice and a bottle of medicine is probably not so good as 
club practice ; and panel practice, as far as patients are 
concerned, differs little from club practice except that the 
scope of treatment given is rather more limited. The 
investigation in the following pages relates mainly to 



practice in the poorer quarters of towns, where conditions 
are often demoralising for the doctor, and treatment futile 
for the patient. In better-class districts the conditions 
are not so bad, and in rural districts the efforts of the 
doctor are aided by the healthiness of the surroundings. 

The main reasons why general practice, whether 
private or contract, is unsatisfactory among the working 
classes are: (1) many doctors attempt to do a great deal 
more work than they can possibly manage satisfactorily, 
with the result that their patients are not properly ex- 
amined and treated ; (2) the facilities for obtaining con- 
sultant assistance, or expert diagnosis, or special forms of 
treatment are very limited ; and (3) the environmental 
conditions of many patients are so bad that medical treat- 
ment is often useless, and the doctor, unable to do more, 
falls into the habit of continually giving medicine as a 
' placebo.' In view of the proposals which are now put 
forward for modifying the panel service or establishing 
some form of a national medical service it is desirable 
to examine each of these factors somewhat more fully. 

The Size of Working-Class Practices 

It is impossible to lay down a hard-and-fast limit to the 
number of persons one doctor can attend satisfactorily, 
for this depends upon the amount of sickness in the district, 
the capacity of the doctor, and the distribution of his 
practice ; but it is well known that many practices are far 
too large. A considerable number of panel doctors, work- 
ing without partners or assistants, have 2000 insured 
persons on their lists ; some have 3000, and even 4000 is 
reached. Most of these are undertaking private practice 
as well, and if we assume that on the average each insured 
person connotes one and a half dependents, it follows that 
a doctor with a panel list of 2000 has actually a total 
clientele of some 5000 persons. Many instances have been 
given of the way in which doctors with these large practices 
rush through their work in order that they may see all 
their enormous number of patients. Dr. Alfred Salter, 
speaking in 1914 at a public meeting in support of a 


national medical service, stated that he saw "on an 
average 76 cases in the morning and 92 in the evening. 
It worked out at 3 J minutes for each patient, lj of which 
was taken up in writing. Patients had to wait on an aver- 
age 2| hours for their turn, unless present at the very- 
start." * 

In an investigation at Cambridge by the Insurance 
Commissioners into the conduct of a panel practitioner, 
whose dispenser had written prescriptions and given 
medical certificates, it was shown that the practitioner's 
consultations and visits to panel patients in 1914 amounted 
to 12,457, and that with private patients the total was 
brought up to 20,660. 2 

It is frequently said that this is a result of shortage 
of doctors in working-class neighbourhoods ; and statistics 
have been issued to show that while there is one doctor to 
every five or six hundred of the population in good- class 
neighbourhoods, there is only one to every two to four 
thousand in working-class districts, though as a matter of 
fact the proportion is rarely less than one to three thou- 
sand even in the worst-provided districts. But none of 
these tables are convincing, since they all ignore the 
hospitals, which appreciably relieve the doctors in the 
poorest neighbourhoods, while there is no means of com- 
puting accurately the number of assistants the doctors 
may have. 

As a matter of fact, large practices are far more due 
to unequal distribution of patients than to shortage of 
doctors. In many towns one-fifth of the doctors attend 
more than half the insured persons. 3 The tendency for the 
bulk of medical practice in working-class districts to pass 
into the hands of a relatively small proportion of the 
doctors, noticeable before the passing of the Insurance Act 
and equally observable in Germany, is the direct result of 
' free choice ' of doctor. It might have been supposed 
that the long delays in crowded waiting-rooms and hurried 

1 Medical World, April 1914. 2 Hospital, September 18, 1915. 

8 In Bradford in 1913, seven medical men earned from panel practice between 
£1000 and £1500; two between £800 and £1000; fifteen between £500 and £800; 
thirty-two between £300 and £500 ; thirteen between £250 and £300 ; and twenty- 
nine less than £50. One practitioner, without a partner, had 4000 insured persons 
on his list. — Lancet, March 14, 1914. 


attendance would have led patients to distribute themselves 
more equally, but this has not occurred. The writer has 
spent an evening in the surgery of a panel doctor where 
over seventy patients were seen in the course of three hours. 
Some of these had been waiting their turn for hours, and 
towards the close of the evening they were shown into the 
consulting-room three at a time. A short distance up the 
street a very capable doctor saw less than a dozen patients 
during the same evening. The fact is that there is as 
much fashion in doctors and desire to go to the " best man " 
in Mile End as in Mayfair, and when once a doctor has 
earned a reputation, people prefer to put up with any 
amount of inconvenience in order to see him, rather than 
go to his less busy but less well-known neighbour. Psycho- 
logy was forgotten when ' free choice ' was given under 
the Insurance Act. It is important to realise the strength 
of these tendencies, since some of the impossible schemes 
for a national medical service seek to retain free choice 
and at the same time distribute patients among the doctors 
approximately equally. If free choice is to be observed, 
we cannot fix any limit to a doctor's practice ; and if, on 
the other hand, excessive numbers are to be prevented 
free choice must be abandoned. 

The ' Lightning ' Diagnosis 

The immediate effect of attempting to treat such large 
numbers is to encourage hasty and inefficient work. There 
is not time to make an adequate examination of the 
patient, and since the great bulk of those who come to the 
surgery are suffering from relatively trivial ailments, the 
doctor jumps to his conclusion after a few questions and 
a superficial investigation, with the result that serious 
errors are made from time to time, as Coroners' inquests 
and reports of Insurance Committees and Approved 
Societies have shown. The best picture of panel practice 
under these conditions has been furnished by a panel 
practitioner himself in the two following letters to one of 
the medical journals : — x 

1 Medical World, April 2 and 16, 1914. 


Sir, — Much, is said about the 'lightning diagnosis' that busy- 
panel doctors must make. I hope Mr. Parker will not be greatly 
upset when I inform him that I often see from 60 to 70 patients of an 
evening between 6.30 and 9, i.e. an average of one every two minutes. 
And yet it is very simple. Each patient on entering the surgery is 
presented with a numbered ticket by my nurse. This, I may say, is 
much appreciated and prevents confusion and waste of time. I 
have already seen, during the past week, nine-tenths of my to-night's 
visitors. To my question, " How are you getting on ? " the answer 
as a rule is, "Very well, but I think another bottle would help me 
more." The prescription is ready as they utter the last word. A 
number want documents signed, leaving me plenty of time to 
thoroughly examine the seven new patients. " But they are all 
trivial cases," I think I hear some one say. Is not almost every 
deviation from the path of health trivial ? Let us look at a few of 
our to-night's ' trivial ' cases. No. 1, chill ; No. 2, eczema ; No. 
3, dyspepsia ; No. 4, alveolar abscess ; No. 5, chill ; No. 6, sprain 
ankle ; No. 7, ulcer leg ; No. 8, injury to foot ; No. 9, chill ; No. 
10, chronic nasal catarrh ; No. 11, neuralgia ; No. 12, chill ; No. 13, 
dyspepsia ; and so on. Who will say that one of these is trivial ? 
Yours, etc., An Old Hand. 

In a second letter the ' Old Hand ' lets us more fully 
into the secret of his methods. He says, in reply to 
criticisms : — 

Thanks to an excellent training at the ' London ' in the ' spot- 
ting class ' (20 years ago), plus a study of the methods of Dr. Bell 
(Sherlock Holmes), it does not take long to sum up a patient. When 
to these are added the mastication and assimilation of such books 
as Malingering, Emergencies of General Practice, the latest books 
on skin, eyes, ear, etc., I am equipped for my night's work. My 
to-night's new patients number seven. The first is ' indigestion.' 
I hand the patient a printed slip, ' What to eat and what to avoid,' 
and ask him to keep it for reference. After a few enquiries as to 
the kind of indigestion I hand him my prescription. No. 2, urticaria. 
I knew at once, in this district, that fried fish is most likely the cause. 
I tell her that two days ago she had fried fish for supper ; she 
admits the soft impeachment, and with a little good advice she 
departs, happy in mind that it is not S.F. 1 No. 3, neuralgia. It 
ranges between temple and jaw. The offending molar is at once 
detected, and a visit to the dentist advised. Nos. 4 and 5, chills ; 
quick pulse — " \ min. thermometer." " Go to bed at once ; take the 
medicine, and I shall call to-morrow to see you." No. 6, a man 
hobbles into the surgery — injury to foot. I inquire kindly, " Why 

1 Scarlet fever. 


didn't you send f or me ? " "I thought I could save you the trouble 
of calling." (Bless them ! Almost without exception they wish to 
* save trouble ' ; they are very good.) I advise the man to go home 
and I will follow at the close of surgery. No, 7, lumbago. 

It would be unfair to class all panel practitioners with 
the ' Old Hand/ nevertheless he describes a type of con- 
ditions which is far too common. Six out of his twenty- 
cases mentioned are diagnosed as ' chill/ to be seen to- 
morrow, but meanwhile medicine prescribed ; the patient's 
own statement that she requires more medicine is accepted 
without question and the prescription given at once ; the 
newcomer's own diagnosis of indigestion received without 
examination and medicine ordered ; printed slips kept in 
order to save the time of verbal advice ; while the one 
useful service which would have been worth all the pre- 
scriptions, viz. extraction of the ' offending molar,' is 
not performed. We can understand how with these 
methods the ' Old Hand ' gets through his large number 
of cases, but it is not easy to see when he manages to 
' masticate and assimilate ' the ' latest books on skin, 
eyes, ear, etc' and how these assist him. 

These large practices are generally mixed private and 
panel, the treatment given to private patients being 
essentially the same ; but instead of a prescription the 
private patient receives a bottle of medicine, usually drawn 
from a ' stock-mixture ' made up in large quantities for 
all and sundry, the fee for advice and medicine averaging 
about a shilling. Such practices can only be carried on by 
means of a machine-like system, and the doctor has rarely 
time to read current medical literature or keep proper 
medical records of his cases. Minor surgery is performed 
in a manner which would horrify a surgeon. There is no 
time to sterilise properly instruments, hands, or skin. The 
writer on one occasion saw a doctor at the close of three 
hours' surgery open a deep abscess in the breast by an 
incision an inch and a half long. The knife was just 
dipped into a weak solution of carbolic acid, no attempt 
was made to sterilise the skin in any way, and there was 
no suggestion that the patient should have even a local 
anesthetic. The girl paid her shilling, but refused to let 


the doctor call the next day, as she could not afford a 
further fee. 

The big panel and dispensary practices are exceedingly 
lucrative, but they are demoralising to both patients and 
doctors. It is but fair to recognise however that in 
many smaller practices and in large practices where suffi- 
cient medical assistants have been engaged, considerably 
better treatment is given. 

The Absence of Expert Assistance 

The poor cannot afford the fees of consultants, and no 
provision is made under the Insurance Act for this form 
of assistance, so freely sought in better -class practice. 
The doctor therefore, unless he sends his patient to a 
hospital, must rely upon his own knowledge for diagnosis 
and treatment in every form of difficulty. He must be 
surgeon, physician, and gynaecologist in one ; he must 
undertake the treatment of grave cases which emphatically 
ought to be in hospital ; advise on the feeding, care, and 
treatment of infants ; attend women in pregnancy and 
childbirth ; do his best for patients waiting for surgical 
operation ; give anaesthetics for a brother practitioner, 
and attend many cases of infectious disease in children. 
For the purposes of diagnosis he should be able to employ, 
and have time to employ, scientific instruments of pre- 
cision, such as the ophthalmoscope and the laryngoscope, 
the use of which he learnt in his student days. He should 
be capable of making skilled investigations of the blood 
and the excreta. Finally, he may be called upon in an 
accident or emergency to perform almost any service in 
the whole range of medicine or surgery. Besides his purely 
clinical duties the modern doctor must observe a long 
series of legal obligations, rules, and regulations relating 
to notification of disease, keeping records, giving of certi- 
ficates, etc. We are accustomed to regard specialism as 
demanding the higher degree of mental attainments, but 
as a matter of fact the specialist, limited to one subject, 
does not embrace anything approaching the wide and 


varied volume of knowledge expected of the general 

Besides being unable to obtain expert medical assist- 
ance, the doctor is further handicapped by absence of the 
accessory but exceedingly important aids to medical 
treatment which are at the command of the wealthier 
classes, such as skilled nursing and invalid food ; and he 
may have to attend his patient in a sick-room which is 
small, noisy, dirty, and depressing. 

Diagnosis in General Practice 

Considering the circumstances of general practice in 
poor urban areas, it is not surprising that serious mistakes 
are made by doctors. We have already noticed the im- 
portance of accuracy in diagnosis, and it is probably in 
this respect that most errors are made, partly owing to 
insufficient facilities for skilled methods, and partly owing, 
it must be admitted, to failure of the doctors to utilise 
these facilities when they are available. In regard to 
phthisis in children, for example, Dr. Hugh Thursfield, of 
St. Bartholomew's Hospital, writes : "In the course of a 
year I have to examine a large number of children who 
have been certified as the subjects of pulmonary tuber- 
culosis, and I do not exaggerate if I say that in at least 
two-thirds there is no evidence whatever of the existence 
of the disease." 1 

The statistics of erroneous diagnosis made by doctors 
when notifying cases of infectious disease in London are 
shown in the tables of admissions to the hospitals of the 
Metropolitan Asylums Board. In 1913 the number of 
patients sent from their homes to the fever hospitals on 
doctors' certificates was 27,746, and of these 2501 were 
found not to be suffering from the diseases certified. The 
following table shows the cases in detail : — 

1 Medical World, June 16, 1916. 


Admissions to Fevee Hospitals of the M.A.B. 

Disease certified. 

Total Admissions 
direct from Home. 

Number not 

suffering from 

Disease certified. 

Scarlet fever 


Enteric fever 



Cerebro-spinal fever 

Puerperal fever 



Smallpox . 

























It may be noticed that nearly 16 per cent of the cases 
sent in as diphtheria, and more than 40 per cent of those 
sent in as enteric were suffering from other maladies. 
Among the cases wrongly diagnosed as one or other of the 
notifiable diseases were 927 instances of tonsillitis, 288 of 
erythema, 152 of German measles, 77 of pneumonia, 70 of 
laryngitis, 59 of bronchitis, and 230 in which no obvious 
disease could be found on admission. A considerable 
number of these persons must have been acutely ill, for 
111 of them died while in the fever hospitals. 

These statistics are for the whole of London, but when 
we examine the experience of individual hospitals we find 
considerable variation in the proportion of errors. In 
admissions for scarlet fever, the percentage of errors was 
10'G at the Eastern Hospital and 1*6 at the Brook Hospital. 
For the same two hospitals the percentages of errors in 
admissions for diphtheria were 29 '9 and 81 respectively. 
It is difficult to account for these wide local variations, 
except on the view that the hospitals with the high per- 
centages of errors draw a larger proportion of their patients 
from the poorer districts, where the doctors devote less 
time and attention to their patients. 

These figures are startling, but it must be remembered 


that some cases are very difficult to diagnose, and that 
in doubtful case's doctors are encouraged to notify rather 
than to wait until clear indications develop. On the other 
hand, these are not cases overlooked in the hurry of surgery 
work, but patients who presumably have been very care- 
fully examined ; the practitioner is under no obligation to 
notify until he is satisfied of the presence of the disease ; 
and in doubtful cases the opinion of the Medical Officer 
of Health can usually be obtained. After making every 
allowance for difficult cases it is certain that the percentage 
of errors is much too high. The Medical Superintendent 
of one of the largest fever hospitals has stated that in 
at least two-thirds of the cases wrongly diagnosed, the 
mistake ought never to have been made. The experience 
of the M.A.B. hospitals for diseases other than infectious 
fevers shows that when patients are under conditions for 
efficient examination very few errors need occur. Among 
the patients in these hospitals 73 cases arose which were 
diagnosed as infectious fevers and were sent to the fever 
hospitals, where only one was found to have been wrongly 
diagnosed. These figures illustrate in striking manner the 
ineffectiveness of general practice under present conditions. 
Speaking of working-class practice, Dr. Newsholme 
says : " This practice will not be likely to be satisfactory 
unless patients under its conditions have the same modern 
facilities for diagnosis as are commonly available for 
hospital patients." 1 In regard to the special examination 
of sputum in suspected phthisis he says : " After making 
full allowance for the varying extent to which practitioners 
examine sputa for themselves, or have them examined 
in private laboratories, there can, I think, be no doubt 
that this aid to the diagnosis of tuberculosis is greatly 
neglected in a large portion of the country." 

The Lack of Laboratories for Special Diagnosis 

Most of the larger Local Authorities, including the 
Metropolitan Borough Councils, now undertake bacterio- 
logical examinations in cases of suspected diphtheria and 

1 Annual Report to Local Government Board for 1913-14. 


enteric fever for practitioners free of charge, and where 
such facilities are available, the doctor alone is to blame 
for not making use of them. But these opportunities are 
not provided everywhere, and facilities for investigations 
less frequently required, such as examinations of blood, 
excretions, and new growths, and diagnosis by X-rays, 
are almost non-existent except on payment of fees. The 
importance of providing public laboratories for these 
purposes was frequently mentioned in debates and dis- 
cussions on the Insurance Act, and it was actually made 
a condition of the extra-Parliamentary grant for medical 
benefit that doctors should employ these modern methods 
of diagnosis; but the Insurance Commissioners have not 
yet taken any steps to provide the laboratories necessary 
for the doctors to fulfil their obligations. For the first 
two years after the passing of the Act no thought seems 
to have been given to the matter at all ; for 1914-15 a 
sum of £50,000 was voted by Parliament for the purpose, 
but still no action was taken and the money was not spent ; 
in 1915-16 a sum of £25,000 for pathological laboratories 
was included in the estimates but was vetoed by Parlia- 
ment. The provision of facilities for expert diagnosis 
would not have been a difficult matter. The cost is not 
high ; there are no vested interests to be overcome, and 
the laboratories of Local Authorities, hospitals, univer- 
sities, clinical research associations, etc., afford opportunities 
for making arrangements. It is impossible to find any 
other reason for the failure to provide these facilities than 
sheer official lethargy or ignorance of their need. As a 
nation we are frequently reproached for not sufficiently 
employing scientific methods, but in this case the fault is 
not with the people, nor the doctors who have shown the 
need, nor Parliament, at least up to 1915-16, but with the 
highly - paid administrators who draw their salaries and 
neglect their public duties. In a later chapter proposals 
will be made to decentralise much of our Public Health 
administration, increasing the powers of Local Authorities 
and diminishing these of the central departments. Since 
it is urged against this proposal that Local Authorities are 
apt to neglect Public Health duties and require ' gingering ' 


by the central authorities, it is well to bear in mind that 
the latter are often quite as much in need of this process 

The Futility of Treatment in a Bad 

Perhaps the most disheartening feature of medical 
practice among the working classes is the hopelessness of 
attempting to produce any permanent and substantial 
improvement in health under existing conditions of the 
environment. We can realise this by studying rather 
more closely the nature of the ailments from which the 
patients who throng the doctors' surgeries suffer. A 
large proportion of these, as indeed of all the working 
classes in large towns, are not suffering from definitely 
definable diseases, but are in a state of chronic ill-health, 
which is variously described as ' debility,' ' run down,' 
' out-of -sorts,' etc., the result of a life of toil in insanitary 
surroundings. Another large group suffer from ailments 
to which more definite names can be given, such as anaemia, 
dyspepsia, nervous breakdown, varicose veins and ulcer- 
ated legs, milder forms of bronchitis, chronic rheumatism, 
and effects of decayed teeth ; uterine displacements in 
women ; and rickets and malnutrition in children ; all 
conditions not in their early stages serious, nor even neces- 
sarily incapacitating for work, but sufficient to make fife 
wretched, and to serve as thef oundationf or graver maladies. 

The fact we have to realise is that these people are 
urgently in need of fresh air, rest, and good feeding, and 
that medical treatment can do little for them beyond giving 
temporary relief to symptoms, so long as their surroundings 
remain unchanged. The practitioner may treat the shop- 
assistant suffering from varicose veins or ulcers with 
ointments for months, but only a prolonged period of rest 
will be of any real benefit. He may prescribe quarts of 
bismuth aod soda mixture for the chronic dyspeptic, but 
so long as his patient lives on unsound or unsuitable food, 
or has only a hurried interval for his meals before resuming 
work, the symptoms will continue. He may prescribe 


without result cod-liver oil and Parrish's food for the slum 
child, whose daily breakfast (and often dinner and tea as 
well) consists of tea and bread and jam, and he will find 
grey powder and citric acid useless for the sickly infant 
needing plenty of good fresh milk. He may vainly dose 
with phenacetin the woman who is suffering from continual 
headaches while sewing all day in a hot stuffy room, per- 
haps with an error of refraction which he could probably 
neither measure nor prescribe for. 1 Only a change of 
environment will produce any lasting improvement in 
the great majority of these patients. The anaemic girl 
must be taken away from her daily life in the scullery ; the 
woman with the displaced uterus from her charing ; the 
chronic bronchitic from the fog and dust of cities; and 
the neurasthenic from the noise and turmoil of the street 
or factory. But the general practitioner possesses no 
magician's wand to effect these transformations, and he 
cannot send his patients empty away. Hence he falls 
back upon medicine as the only procedure which has a 
semblance of giving help, and all his patients receive their 
iron and strychnine ' tonic,' pill, or ointment as a wholly 
inadequate substitute for the real measures their condition 
demands. As a very able panel practitioner once re- 
marked to the writer at the end of a heavy evening's 
surgery : " Well, I have prescribed many gallons of 
medicine to-night, and if I could have given each one of 
these people a good square meal it would have done them 
a great deal more good." 

The Apotheosis of Drugs 

Unfortunately belief in the curative value of drugging 
is now firmly established in the minds of all classes of 
the community. This is the result partly of mediaeval 
tradition and partly of the unscrupulous devices of the 
patent-medicine vendor ; but doctors themselves are also 

1 The referees appointed by the Insurance Commissioners to adjudicate on the 
scope of medical benefit, have decided that testing the eyes for errors of refraction, 
and prescribing as a result of the test, is not a service which " consistently with the 
best interests of the patient, can properly be undertaken by a general practitioner 
of ordinary professional competence and skill." 


in a measure responsible. Sir Clifford Allbutt has said : 
Physicians resent all that savours of quackery, at any 
rate in medicine ; yet is there any custom more apt to 
engender and to foster quackery than to encourage snobs 
to wander round our halls for potions to be hugged to their 
bosoms as charms ? In not a few cases, it is true, these 
herbs and salts have some virtue ; but in how many are 
they not stock receipts, either wholly futile or at best 
impotent as auxiliaries against unwholesome habits and 
conditions of life which the physician, unable to 
ameliorate, gets weary of denouncing ? Too soon he 
learns to say to himself, ' Poor creatures, errant or 
sinful, God help them, I cannot ; yet if pill or potion 
be a comfort to them, or a hope, by all means let them 
have it.' And the quackery does not end here ; 
unhappily it permeates into the higher social ranks, to the 
degradation of scientific therapeutics." 1 
It is not probable that doctors will relegate drugs to 
their proper and useful sphere, any more than the sister 
profession, the Church, will officially abandon beliefs now 
recognised by educated persons as erroneous; for prescribing 
is the only element of mystery left in medical treatment. 
But the result is a wholly exaggerated idea of their value in 
the public mind. The worst feature of this belief is that it 
is shared by legislators, and under the Insurance Act some- 
thing like one and a half millions are provided annually 
for medicines, while the far more urgent need for specialist 
services and nursing are entirely neglected, surgical and 
medical appliances are restricted to the barest minimum, 
and the extra food for consumptives is rigidly limited. 
All over the country a large staff of salaried officials are 
employed in checking prescriptions given by panel doctors, 
which probably number not less than thirty millions a 
year, while a sick person has no right to even an occa- 
sional visit from a nurse to perform a special service. The 
amount spent by the community on the purchase of drugs, 
whether from doctor, chemist, or through the Insurance 
Act, must be enormous, and the sale of patent medicines 

1 Hospitals, Medical Science, and Public Health. An address delivered at the 
opening of the Medical Department of Victoria University, Manchester, 1908. 


has actually increased since the Act came into force, pre- 
sumably as a result of the general advertisement given by 
the Government to medicines. How much better would 
this money be spent in removing some of the conditions 
which lead to the demand for drugs ! 

The Discontent with the Panel System 

Dissatisfaction with the panel system is widespread. 
The doctors complain that they are harassed by unneces- 
sary regulations and circulars from administrative author- 
ities ; that sick visitors and agents of Approved Societies 
interfere with their treatment of patients ; that their 
certificates are sometimes overruled ; that an excessive 
amount of clerical work is required from them ; and that 
they are not paid fully and promptly. The non-panel 
doctors complain that insured persons are not freely per- 
mitted to be attended by them. The officials of Approved 
Societies state that they cannot rely upon the doctors' 
certificates, and that they do not exercise sufficient care 
when examining patients. Insured persons complain 
that they do not get proper and sufficient treatment ; 
that a distinction is made between them and private 
patients ; that sometimes they cannot get a doctor at all ; 
and that sometimes they are made to pay for services to 
which they are entitled without charge. 

There is a large measure of truth in all these com- 
plaints, but the fault lies far more with the circumstances 
and the system than with the doctors who are often 
working under conditions of exceptional difficulty. The 
panel system was unsound from the beginning. It was 
based upon a form of contract practice which had never 
been ideal, and it worsened rather than improved the 
previous system. It does not meet the crying need of the 
working classes for greater hospital treatment. It expects 
the doctor to perform satisfactory work in the worst en- 
vironments without giving him assistance from consultants, 
facilities for skilled diagnosis, or nursing ; it does nothing 
to increase his interest in the scientific side of his profes- 
sion ; and it perpetuates competition between doctors 


instead of establishing co-operation. A national medical 
service at least could not be less satisfactory ; but the best 
solution is probably to be found in giving Local Authorities 
power to establish municipal medical services with wide 
latitude as to the form of the service, according to the 
needs and circumstances of each district. 

Medical Treatment of School Children 

We have seen that roughly about one -third of the 
school children in England and Wales undergo a medical 
examination in the course of the year, and from the number 
found defective it was estimated that the total number of 
school children who require medical treatment is more 
than a million and a half. But detection of a defect by 
no means assures its treatment. The school doctor who 
examines the child is precluded from undertaking treat- 
ment, and, except in districts where the Education 
Authorities have made special arrangements, recourse 
must be had to private practitioners or the Poor Law. 
Under these conditions it is inevitable that a large number 
of children should fail to receive treatment. There is no 
return for the whole country of the number of children who 
receive treatment, but the following table relating to some 
59 school areas, representing a total average attendance 
of about 754,000 school children, shows how large is the 
field still to be covered : — 

Medical Treatment of School Children 1 

Number of defects needing treatment . . 131,157 

Number of defects treated .... 74.124 

Number of defects not treated . . . 32,375 

Number for which no report is available . . 24,658 
Results of treatment — 

Remedied 42,884 

Improved ...... 24,915 

Unchanged ...... 6,325 

It appears therefore that less than 60 per cent of the 
defects found were treated actually, and only about 33 

1 From the Report of the Chief Medical Officer to the Board of Education for 


per cent were remedied, while a smaller percentage appear 
under the somewhat elastic title of ' improved.' Since 
only one-third of the school population comes under 
medical inspection in the year, and since only one-third 
of the children found defective on inspection have their 
defects remedied, it follows that out of the total mass of 
defectiveness the school medical service is still only correct- 
ing one-ninth in the course of the year. And be it remem- 
bered that at the best the school medical service only 
deals with chronically defective children. Except for 
infectious diseases there is no State provision for the 
many thousands of children who in serious illness are 
kept at home. It is obvious that the present system 
can have only a very limited effect upon the great mass 
of sickness and defectiveness among school children. 

To provide merely for the medical inspection of every 
school child once a year would entail trebling the present 
staff ; and it may be noted that, since they are not followed 
by treatment, more than 40 per cent of the inspections 
are wasted, except for the statistical information they 

The failure to provide medical treatment is due partly 
to parents not appreciating the importance of having their 
children treated, and partly to their inability to pay 
doctors' fees in the absence of other facilities. Poor Law 
medical relief can sometimes be sought, but parents are 
often reluctant to take this course, and the treatment 
available may be insufficient. The school medical officer 
for Shropshire writes : — 

" In cases where the parents are unable to afford 
treatment and cannot get charitable help, one is compelled 
to suggest application to the Guardians. It cannot be 
considered that this is satisfactory from any point of view. 
Parents who have never had poor law relief do not care 
to apply for treatment of defects in their children which 
to them often appear trivial. The result in many cases is 
that the parents deny that any defect exists and refuse to 
do anything. Nor have the Boards of Guardians any 
special facilities for the provision of treatment for the 
defects of the eye, ear, and throat, which form the large 



majority of the defects amongst school children requiring 
treatment." x 

A welcome development during recent years has been 
that of school clinics, which now number upwards of 350, 
and are to be found in nearly all the large towns. The 
system is steadily growing, but the number of clinics is 
still far from sufficient to meet the demand, and many of 
the clinics limit the scope of the treatment they give, some 
treating minor ailments only, others errors of refraction 
alone, and others confining themselves to dentistry. 
Besides establishing school clinics, some Local Authorities 
have now made arrangements with hospitals for the treat- 
ment of school children, and in some districts special 
institutions have been provided for the treatment of 
tuberculosis, ringworm, and ophthalmia. 

Defectiveness in school children, as most disease else- 
where, is mainly a matter of environment ; and the most 
economical course in the long run is to prevent defective 
conditions arising by enlarging playgrounds, increasing 
open-air classes, and similar measures. Nevertheless it 
would be well worth while to establish a thorough and 
efficient system of school medical inspection and treatment, 
for in children medical treatment yields a greater return 
than in adults. Children can often be permanently bene- 
fited by early attention to the throat, ears, eyes, or teeth, 
whereas in adults often little can be done. Probably the 
best plan for the community would be to place treatment 
as well as inspection in the hands of the school doctor, who 
should be definitely attached to a group of schools, should 
be a specialist in diseases of children, and should be pro- 
vided with a properly-equipped centre at which minor 
operations could be performed. It is no use however 
disguising the fact that this course would arouse great 
hostility among a section of general practitioners. 2 

In rural districts we might with advantage adopt the 

1 Quoted in Report of Chief Medical Officer to the Board of Education for 1913. 

2 The following resolution was passed by the British Medical Association in 
1914 : " Treatment by an education authority should be confined to necessitous 
children — that is, to those children whose parents cannot afford to pay privately 
for the treatment recommended as a result of inspection. Parents should always 
in the first place be recommended to seek treatment for their children from their 
family doctor. 


system of travelling school hospitals which has been very- 
successful in Australia. The unit could consist of a small 
medical staff, including an oculist and a dentist, and should 
be properly equipped with the necessary appliances. It 
would travel about the country from village to village 
attending the children in need of treatment, and would thus 
bring a very large number under treatment in the course 
of the year at comparatively small cost. 

An important adjunct to the school medical service is 
the school nurse. She helps to treat minor ailments and 
uncleanliness, and is of great service in ' following up ' 
cases recommended for treatment. 1 The Medical Officer 
to the Board of Education considers that one nurse cannot 
deal with a school population of more than from 2000 to 
3000, an opinion with which those familiar with the con- 
dition of school children will thoroughly agree. But in 
England and Wales as a whole there is still only one nurse 
to about every 6000 children, counting two part-time 
nurses as one whole-time. Thus to bring the nursing 
staff up to even the minimum standard we should have to 
double the number of nurses at present employed, though 
this again would be a thoroughly sound and economical 
step. The money we are now spending on a large staff of 
insurance prescription checkers would have yielded far 
greater return if it had been employed in increasing the 
school nursing service, for the school nurse exerts a direct 
and immediate influence upon the health of the school 

Mortality in Child-bed and its Causes 

The number of deaths of mothers in England and Wales 
from pregnancy and child-birth averages about 3500 per 
annum in roughly 880,000 births, that is one death in 
about every 250 births. This rate has not varied widely 
for a considerable number of years, as may be seen from 
the following table : — 

1 In Sheffield, in 1915, the school nurses made 83,793 examinations of children 
for the treatment of uncleanliness alone, and many more for other purposes. 



Deaths per 1000 Births.* 

1899-1908 . 

. 4-22 


. 3-70 


. 3-56 


. 3-67 


. 3-78 


. 3-71 


. 3-95 

* Exclusive of deaths from puerperal nephritis and albuminuria. Up to 1911 
these deaths were not classified as puerperal, and to make the figures comparable 
they have accordingly been deducted in the rates for 1911 and subsequent years. 
Their inclusion would raise the figures by about *25 all through. 

It is of course very desirable to prevent this loss of life 
as far as possible ; and the belief that much of it is due to 
bad surroundings and lack of skilled assistance at birth 
has led to a strong movement for increasing medical and 
midwifery services, lying-in homes, maternity benefits, 
and similar measures. Nevertheless, knowledge of the 
causation of these deaths is still very imperfect ; and in this 
direction also, as in infant mortality, we seem to have 
jumped to conclusions without adequate investigation. 
Until a year ago few persons would have hesitated to say 
that lack of medical attendance, insanitary surroundings, 
poverty, and working of pregnant women in factories were 
potent causes of maternal mortality. But the whole sub- . 
ject has recently been investigated by Dr. Newsholme and 
his staff, as far as material permits, and their singularly 
interesting report shows that none of these factors can be 
regarded as of overwhelming importance. 1 

Let us note first the distribution of maternal mortality. 
We have seen in previous pages the very marked effect of 
rural conditions in lowering sickness and disease from 
practically all causes ; but when we turn to deaths in child- 
bed, we are at once struck by the fact that the distinction 
between rural and urban environments no longer holds 
good. In the whole of the North of England the death-rate 
is somewhat higher than in other parts of the country, 
but there is very little difference between the rates in the 
aggregate of County Boroughs and of Rural Districts. 

1 " Maternal Mortality in connection with Childbearing and its Relation to 
Infant Mortality," Supplement to Forty-fourth Annual Report of the Local Govern- 
ment Board, 1914-15. 


In the Midlands and the South of England the rural rates 
are slightly higher than the urban rates. The highest 
rates are found in the Rural Districts of Wales. With this 
exception, the cause of which is not clear, the range of 
variation between aggregates of Urban and Rural Districts 
is everywhere small and does not faintly approach that 
exhibited by infant mortality. We have for diseases taken 
for extreme comparison the County Boroughs of the North 
and the Rural Districts of the South, and for maternal 
mortality in child-bed the rates for these areas are respect- 
ively 4 - 35 and 3*76 per thousand births for the period 

When we examine towns we can find no constant 
difference between those which exhibit a high and those 
with a low death-rate. Taking a series of towns in the 
same county, Lancashire for instance, we find the follow- 
ing variations : Rochdale, 7*21 ; Burnley, 6*57 ; Blackburn, 
6'55 ; Liverpool, 361 ; St. Helens, 339 ; and Bootle, 3'08 
deaths per thousand births. These statistics are for a 
period of four years, 1911-14. It is quite possible that if 
they were compiled for a different four years, the towns 
would show a different order, or if they were taken over 
a longer period the differences would disappear. More 
significant perhaps are the variations in the rates in the 
Metropolitan Boroughs. The lowest rates were 281 in 
Stepney, 2"62 in Shoreditch, 2" 61 in Bethnal Green, 2 33 
in Southwark, and 2*06 in Bermondsey. In West Ham 
the rate was 220. The highest rates were 4*73 in West- 
minster, 4*47 in Hampstead, 4*46 in Stoke Newington, and 
3*97 in Chelsea, all districts in which presumably a high 
proportion of mothers are attended by medical practitioners. 
It is a singularly interesting fact that the most poverty- 
stricken districts of London, where the infant mortality is 
the highest, show the lowest rates of maternal mortality ; 
whereas the wealthier districts which have the lowest infant 
mortality have also the highest maternal death-rate. It 
would appear that neither social position nor standard of 
comfort have any greater effect in reducing the maternal 
death-rate than they have in reducing the infant mortality 
rate during the early weeks of life. 


Nor can a consistent relationship be traced between 
excessive mortality from child-birth and a high degree of 
employment in factories. Textile towns as a whole show 
some excess, but there are remarkable exceptions. In 
Nottingham, with 26 per cent of the total married and 
widowed women engaged in non-domestic occupations, 
the mortality rate was 3 "79 per thousand births ; whereas 
in Halifax, with only 16 per cent of the women so em- 
ployed, the rate was 623. The experience of rural Wales 
shows that a high rate of maternal mortality can exist 
where only a few women are engaged in factory work. 
Unexpected too is the conclusion that maternal mortality 
from child-bearing appears to be largely independent of 
general sanitary conditions, some towns with a low 
standard of general sanitation, such as Bolton and St. 
Helens, showing as low a rate of maternal mortality as 
towns with a much higher standard, such as Croydon. 

Inability to pay for medical assistance or sufficient 
food or other necessaries has often been regarded as a 
cause of maternal deaths, and the primary object of 
maternity benefit was to meet these deficiencies. But the 
experience of the poorest quarters of London and various 
industrial towns does not support this view. Moreover, 
if poverty had been an appreciable factor we should have 
expected that maternity benefit, which, where both husband 
and wife are insured, now provides a sum of £3, would 
have lowered the death-rate. Maternity benefit is not a 
provision the effect of which will only become visible after 
a considerable period, but one which, if it was going to 
produce any effect at all, would produce it at once. Yet 
reference to the table on p. 196 will show that the rate 
has actually risen somewhat during the two years the 
Act has been in operation. In Scotland during the same 
period the rate has risen from 5*5 to 6*0 per thousand 

Finally it may be noted that neither a high nor a low 
birth-rate appears to have any marked influence upon 
the rate of maternal mortality ; and the same may be 
said of illegitimacy. 


Skilled Attendance in Child-bed 

This, the most important question for the purposes of 
the present chapter, was also investigated by the Local 
Government Board; and here again the author of the 
report is unable to come to definite conclusions. In some 
areas where attendance appears satisfactory the death- 
rate is high, while in others with inadequate attendance 
the rate is low. In Newport (Mon.) 74*7 of the total 
births were attended by midwives, and in 18'4 per cent 
the midwives obtained additional assistance from doctors, 
yet the death-rate was 5'28 ; whereas in Newcastle, 
though only 28 '8 per cent of the births were attended by 
midwives, with assistance from doctors in 9*3 per cent, 
the death-rate was 3" 89 per thousand births. Dr. News- 
holme remarks of the statistics on this point that " they 
do not themselves justify any general conclusion as to 
relationship between mortality in child - bearing and 
attendance in confinement by midwives or doctors. Much 
more minute local investigation is required in each County 
and County Borough concerned." 

The Pathological Causes of Deaths in Child-bed 

It is clear from the foregoing summary that the problem 
of maternal mortality, so far from being one which is to 
be solved by the simple provision of more doctors and 
midwives and maternity benefits, is really highly obscure. 
If we had accurate information regarding the pathological 
causes of these deaths, firm conclusions could perhaps be 
drawn just as was possible with infant mortality, but un- 
fortunately the statistics on this point are scanty and 
unreliable. General knowledge however shows that the 
causes of maternal deaths, as those of infants, may be 
divided into two broad classes, viz. (1) abnormalities in 
the mother and defects arising during gestation, most of 
the deaths from which are unavoidable, except perhaps 
with the most highly skilled attendance, and then only to 
a limited extent, and (2) accidents or septic infection 
during or after labour, which must be regarded as almost 


entirely preventable. In the latter group puerperal fever 
is by far the most important and most frequent of the 
avoidable causes of maternal deaths, and we know that it 
is almost always due to failure on the part of the doctor 
or midwife to observe strict antiseptic precautions. 

Puerperal Fever. — If we had statistics which showed 
whether mothers who are attended in child-birth by 
doctors or midwives suffer less from puerperal fever than 
those who receive no skilled attendance, or whether the 
incidence is less among those who are attended by doctors 
than those attended by midwives, we should have a very 
fair means of gauging the effect of medical treatment in 
reducing the death-rate, and of comparing the value of 
doctor and midwife. Unfortunately the statistics on this 
point are on the face of them not reliable. Puerperal 
fever is a notifiable disease, and in towns where there is 
active municipal midwifery supervision the death-rate 
ranges between 20 and 40 per cent of the cases notified. 
Broadly speaking, therefore, notifications should be about 
three times the number of deaths ; yet so negligently is the 
law observed that in ten County Boroughs and in fifteen 
Counties the registered deaths from puerperal fever actually 
exceeded notifications in 1911-14, and in eleven other areas 
the numbers were equal. There is reason to think that 
medical practitioners are more lax in notifying puerperal 
fever than midwives. To a limited extent also the 
statistics are made unreliable by the differences of mean- 
ing attached to the words ' puerperal fever ' by different 
medical men. The term is really an obsolete one, dating 
from the time when the condition was believed to be a 
definite disease, but, unless understood to mean all puer- 
peral septic infections, it ought now to be abandoned. 

General Practitioner or Midwife ? 

But while we cannot be dogmatic, we cannot ignore 
certain indications which appear to point to doctors being 
more responsible for puerperal fever than midwives. Sir 
Halliday Croom, after referring to the great reduction in 
mortality from puerperal fever in lying-in hospitals, says : 


But while these wonderful results have taken place in hospitals, 
mark you, the same has not been the case in out-door practice. 
There the disease still persists, and the death-rate from blood- 
poisoning in private practice still remains very high. Why is it 
so ? Because while in maternity hospitals the nurses and doctors 
are under discipline, and the antiseptic regulations are carried out 
under pain of dismissal, such does not apply to private practice 
where nurses and doctors do as they please. They are taught in 
the maternity hospital the strict and careful use of antiseptics, but 
unfortunately both the attendants become less scrupulously careful. 
... I should like to ask you to look for a moment not only at the 
mortality, but at the morbidity — by that I mean the ill-health 
induced by perfunctory and inaccurate midwifery, . . . the amount 
of ill-health which is induced by unskilful midwifery is endless. . . . 
Among the poorer classes women remain permanently disabled and 
handicapped for the rest of their lives. 1 

It should be pointed out that in so far as Sir Halliday 
Croom's remarks relate to mid wives they do not apply to 
England and Wales, where the Midwives Act has been in 
force since 1905, nor do they now apply to Scotland. 

Dr. George Geddes has made an exhaustive investiga- 
tion of puerperal sepsis in Lancashire, and he finds that 
at least midwives are not more responsible for causing 
puerperal fever than are doctors, while some of his statistics 
show that they are far less so. In the residential town of 
Blackpool, for instance, the puerperal rate among women 
attended by midwives was 2'4, and among those attended 
by doctors it was 4*8 ; in the mining town of St. Helens 
the midwives' rate was 1'7, while the doctors' rate was 
13'2. Dr. Geddes attributes the excess among doctors 
in mining districts largely to the fact that they are so 
frequently dressing small septic injuries from which they 
go straight to their maternity cases. 2 

In studying the relative advantage of doctor or mid- 
wife it is important to bear in mind that child-birth is not 
sickness but a natural process; and there is good reason 
to believe that the great majority of mothers, in the 
absence of medical attendance, would go through their 

1 Address delivered at a conference of Delegates of Approved Societies, Edin- 
burgh, 1915, on the invitation of the National Health Insurance Commission 

2 Etiology and Distribution of Puerperal Sepsis, 1913. 


confinements safely without further assistance than that 
of some one sufficiently skilled to perform certain necessary 
but simple services as soon as the child is born. In by 
far the larger number of cases the ideal treatment is to do 
little beyond encouraging the mother and relieving symp- 
toms of discomfort. This course may somewhat prolong 
labour, but in the long run it is the best for both mother 
and infant, the absence of intimate examination or use of 
instruments enormously diminishing the risk of puerperal 
fever. Midwives are severely restricted in the methods 
of this nature which they may employ. But it will be 
objected that, while this is quite true, the presence of a doctor 
is important in order that he may do what is necessary in 
the exceptional complicated case. In theory this is so, 
and if doctors always adopted the expectant attitude, and 
only interfered when occasion really demanded, no criticism 
could be made. Unfortunately it is well known that in 
working-class practice, and even to some extent in better- 
class practice, this is far from being the case. The fees 
paid for attendance in confinement are disproportionate 
to the time which the case demands if properly dealt with ; 
and the doctor may have a long list of patients to see, or 
may be anxious to get back for his consultation hours. 
He is consequently under strong temptation to cut short 
the case by applying the forceps at the earliest possible 
moment ; the instruments are often not properly sterilised 
— indeed in the homes of the poor it may be impossible 
to do this — and the risk of puerperal fever to the mother 
and of injury to the infant is greatly increased. It is 
notorious that this course is adopted in a considerable 
number of uncomplicated cases which if left to themselves 
would terminate naturally. The custom among doctors 
in the poorer quarters of certain towns of leaving the 
earlier conduct of a case to an unregistered midwife and 
rushing in towards the end to finish it off — almost amount- 
ing to ' covering ' — has grown to such an extent that 
the General Medical Council has recently found it neces- 
sary to issue a special warning on the subject. This may 
happen in a case where a doctor has been engaged to 
attend. When a midwife has charge of the case she is 


required to summon a practitioner in certain eventualities, 
the doctor's fee being paid by the Board of Guardians, 
or in some districts by the Local Authority ; and if the case 
is one which ' requires the use of instruments,' the doctor 
receives an additional fee. Some of these cases demand 
the highest skill of a gynaecologist, but the general practi- 
tioner cannot have, and does not profess to have, this 
degree of skill. Undoubtedly he saves life in some 
instances, but we must look at the matter as a whole, and 
unfortunately there is no doubt that in working-class 
practice a considerable amount of harm is done by hasty, 
unnecessary, or unskilled interference. The harm is not 
represented only by deaths. A much larger number of 
women suffer permanent ill-health or discomfort from 
injuries received or sickness caused. 1 

We have noticed the exceptionally low rates of 
maternal mortality in the poorest districts of London, 
and at first sight it might appear that this is inconsistent 
with the foregoing remarks. But it must be remembered 
that a large proportion of the mothers in these districts 
are attended by students from the medical schools, 
who are taught to allow full time for natural delivery, 
and that if instrumental interference becomes necessary 
it will only be done by, or under the immediate super- 
vision of, the skilled resident accoucheur of the hospital 
specially summoned for the purpose. Dr. Newsholme 
considers that this is the most probable explanation of 
the low rates of maternal mortality in these districts. 

We do not know why mortality from child-birth has 
risen during recent years ; and it is possible that the in- 
crease is only an accidental fluctuation. We know that 

1 Dr. Drummond Maxwell, of the London Hospital, writes : " There are ad- 
mitted into the London Hospital a considerable number of cases in which the 
lower genital tract, cervix, vagina, and perineum are lacerated and bruised to an 
almost inconceivable extent. One would almost infer from inspection of these 
cases that the accoucheur had set out to inflict deliberately the maximum injury 
consistent with survival and been thoroughly successful in his aim. ... I am bound 
to say that I do not find the notable improvement that might be expected to follow 
the better teaching in recent years of clinical obstetrics, and I expect one will have 
to wait a few years longer before that teaching bears fruit. Certainly the number 
of mutilated cases one sees is most disheartening, and constitutes a grave indict- 
ment against much of the midwifery of the present time." — The Practitioner, 
February 1916. 


since the passing of the Insurance Act some busy doctors 
have given up attending confinements, and that a much 
larger number of women are now in a position to pay for 
attendance by a doctor, but we have no means of deter- 
mining whether a larger or smaller proportion of births 
are now attended by doctors than before the Act. It is 
however disquieting to find that, comparing 1914 with 
1912, the increase in maternal mortality has been chiefly 
in puerperal fever, and that it has occurred in London 
and the County Boroughs ; the rate in the smaller Urban 
Districts having remained constant, while that in the 
Rural Districts has actually fallen to a small extent. 

Attendance in Confinement and Infant Moetality 

We have already examined this question in an earlier 
chapter, and found no reason to believe that attendance 
in confinement by doctors has any appreciable effect in 
reducing infant mortality. One additional point is all 
which needs mention here. Deaths certified as due to 
' injury at birth ' have been steadily increasing for a 
number of years. In 1900, with 927,062 births in England 
and Wales, the deaths of infants from this cause were 
448 ; in 1914, with 879,096 births, the number was 1051. 
The rates for 1913 and 1914 show larger increases than 
any previous years. It is possible that these figures are 
an indication of the steadily-increasing use of forceps. 

Mateknity Benefit 

Since maternity benefit has failed to reduce mortality 
among mothers, must it then be regarded as a useless waste 
of money ? We will answer this question by quoting 
from an investigation made by Miss Margaret Bondfield 
the two following instances of the deplorable conditions 
under which women may be confined : — * 

Mrs. D. Husband a hawker of sawdust. Woman was confined 
in a cellar, where rats ran about the floor. The door, about \ 
foot from the steps, let all the wind and rain into the place — a 

1 " The National Care of Maternity," New Statesman, May 16, 1914. 


most horrible place. A maternity nurse appealed to a Ladies' 
Charity, but no help came till two days after the confinement. No 
maternity benefit. 

Mrs. F. Husband a casual labourer — deposit contributor — 
now out of work. Had only 2s. to draw. Two rooms only. Four 
girls sleep in one small bed in back room ; boys sleep in parents' 
room. No maternity benefit. 

Maternity benefit is, in fact, an exceedingly valuable 
provision for helping mothers through a period of stress. 
Complaints have been made that the money is wrongly 
expended by mothers, and it has been urged that the 
money should be taken out of their hands and expended 
more judiciously for them by others, which means in 
accordance with orthodox views. But we cannot separate 
one need from another at such a time, and the mother 
alone knows what is most urgently required. Whether the 
money is spent in paying rent, or providing clothes for the 
other children, or food for the family, or taking household 
articles out of pawn, it is none the less serving a very 
useful purpose. Many mothers have employed part of 
the money in obtaining extra assistance in the household, 
and those who know the poor, appreciate what a boon it 
is for a mother who is laid up to be able to get some one in 
to look after the home, keep the children clean, and send 
them to school. If we measure the advantage of maternity 
benefit by the statistics of maternal or infant mortality, 
we shall meet with nothing but disappointment ; but if we 
regard the provision as a means of increasing the mother's 
comfort when most needed, we shall realise what a great 
blessing it has been to many thousands of poor mothers. 

The Question of a Public Maternity Service 

Proposals have been made for establishing a National 
or Municipal Maternity Service, gynaecologists being ap- 
pointed to attend mothers in confinements, and lying-in 
homes provided at the cost of the State. This would be a 
useful step in towns where the number of births is sufficient 
to render it economically sound. In rural districts efforts 
must be mainly directed towards increasing and improving 


the service of midwives. Be it noted however that a 
maternity service — i.e. apart from maternity benefit — is 
by no means our most pressing want. If it be assumed 
that a death-rate of, say, 2 per thousand is unavoidable, 
we should only save 1750 lives in the course of the year, 
and this only when we had covered the whole country 
with the service, necessarily at very great cost. Much as 
this is desirable, we are bound to recognise that the same 
amount of money spent in other directions, for instance 
on a school medical service, would yield a far greater 
return from the Public Health point of view. In any case 
it is clear that before any further large scheme of public 
assistance is contemplated, a thorough and detailed in- 
vestigation of the whole subject is required. 

Medical Treatment and Public Health 

We may conclude this chapter by examining the general 
influence of medical treatment in reducing the death-rate 
and prolonging the average duration of life, particularly 
in view of the proposals now made for establishing a 
national medical service. The first step is to recognise 
the real services which a doctor renders in the social scheme. 
To the individual these services are immense and varied. 
The doctor relieves anxiety of parents and relatives, he 
does much to increase the comfort of his patient, allevi- 
ates symptoms, assuages pain, cheers and encourages. 
If it be held that these advantages alone justify medical 
treatment being placed within the reach of every one, then 
the case for a national medical service is strong. On the 
other hand, if we look at the question exclusively from 
the point of view of Public Health, we must not make the 
mistake — as there is distinct tendency to do nowadays — 
of supposing that medical treatment has a large effect in 
preventing sickness or in reducing the death-rate, that is, 
medical treatment in the limited sense of treatment by a 
doctor, and not as including surgery, nursing, etc. We 
have already noticed the uselessness of much medical 
treatment of minor ailments under existing conditions. 
When we examine more serious illness which keeps the 


patient in bed, we find again that the great service of the 
physician is to relieve and comfort. It is the rest in bed, 
care, and nursing which effect the cure of bronchitis, 
pneumonia, and many other acute illnesses ; medicine is 
almost useless in tuberculosis ; medical treatment of 
cancer is summed up in the word ' morphia.' If doctors 
are necessary to maintain health or prevent disease we 
should not find the healthiest conditions in some districts 
where the doctors are fewest, and the worst in others 
where they are relatively numerous. Connaught has the 
lowest death-rate — 13*6 — of the four provinces of Ireland, 
yet 47*7 per cent of all deaths were not certified in 1914, 
i.e. the persons were not attended even in their last illness 
by doctors. Leinster has the highest death-rate, 17*7, 
yet only 14*7 per cent of the deaths were uncertified. 
Mr. Walter Long has stated recently that during 1915 
Public Health in England has been highly satisfactory, 
yet a large proportion of the doctors have been withdrawn 
from the civil population for special military service. 
This is not to under-estimate the value of medical treat- 
ment, but to recognise the real nature of its services. The 
doctor is not a Public Health officer and never will be ; 
his duties are those of alleviator and counsellor. 

On the other hand, a very different view may be taken 
of modern surgery, which is undoubtedly the means of 
saving many thousands of lives every year. There is 
scarcely an organ of the body which is not now accessible 
to the surgeon, and there is scarcely a disease which, in 
some manifestation or other, is not benefited by surgical 
treatment. Cancer in accessible parts can be completely 
removed, and in women suffering from cancer of the breast 
or uterus a high proportion of cures is effected, while in 
other cases life is prolonged. Surgical treatment is appro- 
priate in many cases of tuberculosis, from removal of 
glands in children to treatment of serious affections of 
joints. Abdominal surgery in appendicitis, acute obstruc- 
tions, ulceration, etc., saves many fives which a generation 
ago would certainly have been lost, while various conditions 
of the lung-cavities, the kidneys, the throat, and other 
organs are cured or relieved by surgical treatment. Among 


women removal of non-malignant tumours of the uterus 
is exceedingly common, and removal of diseased ovaries 
is effected every day in our large hospitals, though when 
the operation was first introduced the coroners threatened 
Lawson Tait with holding inquests on his non-successful 
cases. Even where surgery has not for its immediate 
object the saving of life, it may undoubtedly do this by 
increasing the health of the patient. The large number 
of operations for adenoids in children cannot have been 
without a substantial effect in improving health in later 
years. To the surgical treatment of disease must be 
added that of injuries. Grave conditions, such as fracture 
of the skull and injuries to important organs, can frequently 
be treated successfully, while antiseptic measures have 
substantially reduced blood - poisoning in all forms of 
injury and wounds. The grave septic infections, such as 
1 phagedena ' and ' hospital gangrene,' are now practically 
unknown, and many students go through their whole 
training without ever seeing a case. Nor are the advan- 
tages of surgery limited to saving life, for injuries, diseases, 
and deformities of limbs and joints can now often be treated 
in such a way as to restore the normal functions. 

There can be no doubt that the development of surgery 
has had a very appreciable effect in reducing the death-rate 
and increasing the average age. We have already noticed 
the great increase in the volume of institutional treatment 
in this country ; and pari passu there has been a steady 
decline in the death-rate. As Dr. Newsholme has pointed 
out, this represents an immense change in the conditions 
under which disease is treated in this country. If we could 
pursue the matter further, we should almost certainly find 
that the surgical wards have had a far larger share in pro- 
ducing this result than the medical wards. Surgery has 
perhaps been the greatest factor in the decline of the death- 
rate, which has fallen about 4 per thousand since the 
period 1881-85. If surgery is only saving in each year two 
lives more in every thousand people than it did thirty years 
ago, half the total fall is accounted for. When we add to 
these the effect of natural decline of disease, we see how 
grossly exaggerated are the bombastic claims of those who 


would attribute all improvement in Public Health to 
sanitary services. It may be noted that surgeons them- 
selves have been singularly modest in calling attention to 
the importance of their work in Public Health. 

If we are to establish any form of a public medical 
service we must emphatically begin by providing surgical 
and institutional treatment. Such a service would not 
be so difficult to create as was the panel service, for it 
would not involve interfering with vested interests. More- 
over, the question of free choice of doctor would not arise, 
for the personal relation between doctor and patient, 
rightly insisted upon under the Insurance Act having 
regard to the real nature of the services the practitioner 
renders, need not exist in the case of the surgeon to whom 
in hospital the patient freely trusts his life, though he 
may never have seen him before. A mere extension of 
the panel system, or of any other system on similar lines, 
would be one of the most profitless steps we could take. 



The Insurance Act a Public Health measure — The German origin of the 
Insurance Act — The principles of administration of the Act — Local 
administration — Medical benefit — The supply of drugs — Sanatorium 
benefit — Sickness benefit — The Insurance Act and insanitary con- 
ditions — The Insurance Act and the advancement of Public Health 

The Insurance Act a Public Health Measure 

The National Insurance Act is the most ambitious piece 
of Public Health legislation ever carried through in this 
country. No previous measure has directly affected so 
large a number of persons, involved so great a cost, made 
such demands upon administration, or been introduced 
with such lavish promises of benefit to follow ; and no 
previous measure has ever failed so signally in its primary 
object. In preceding chapters the operation of maternity, 
and to some extent medical benefit, have been considered, 
and we have now to examine the other leading provisions 
of the Act mainly for the lessons which can be derived from 
them, and for the light they throw upon the weak points 
in our present system of dealing with Public Health affairs. 
Probably the greatest obstacle to the development of a 
sound and comprehensive scheme for protecting the health 
of the community has been the failure of legislators to 
appreciate the complexities and difficulties of the questions 
with which they were dealing. Public Health is a science 
which demands years of study for its understanding ; 
many of its problems are obscure, and often the seemingly 
apparent remedies for its defects may be more harmful 
than beneficial. Health legislation in Parliament has 



always suffered from the almost complete absence of 
scientific medical criticism, and the Insurance Act was 
no exception to this rule. In its genesis, in its modifica- 
tions in the House of Commons, and very largely in 
its subsequent administration, it has been the work of 
amateurs, and it contains in consequence the most glaring 

The main object of the Insurance Act was to improve 
the health of the working part of the community, and by 
its results in this direction the Act must be judged. If 
it has not improved the Public Health, or has not improved 
it relatively to its cost, then the Act has failed in its most 
important object. It is necessary to insist upon this point, 
for though there is much discussion of the financial position 
of approved societies, the scope of medical benefit, and 
other questions, the fundamental purpose of the Act seems 
in danger of being lost sight of. 

It is probable that the National Insurance Act was 
indirectly the outcome of the Report of the Royal Com- 
mission on the Poor Laws, that painstaking and ex- 
haustive inquiry to the recommendations of which so 
little effect has been given. Both the Majority and 
Minority Reports called attention to the association of 
poverty with sickness, but neither recommended national 
insurance as a remedy, nor took the view that poverty was 
the main cause of ill-health. The authors of the Insurance 
Act seem' to have believed however that the relation be- 
tween poverty and sickness is much closer than is really the 
case. They do not appear to have realised that poverty — 
short of absolute destitution and consequent starvation — 
exercises hostile influence mainly by compelling a person 
to five in an unhealthy environment, and that it is quite 
possible to be extremely poor and extremely healthy. 
They ignored, or did not know, that the most poorly-paid 
section of the working classes, the agricultural labourers, 
are also the healthiest, and they seem to have come to the 
conclusion that the payment of a small sum weekly during 
sickness, while doing practically nothing to improve the 
environment, would have a great effect in improving the 
national health. This belief gave the Insurance Act its 


essential character, which is that of a palliative rather than 
a preventive measure, and in this respect made it a re- 
versal of nearly all earlier Public Health legislation. There 
is scarcely a remedial provision of the Act which comes 
into force before sickness or disablement is actually present, 
and the few clauses which were intended to deal with the 
environmental causes of sickness have, in practice, proved 

The German Origin of the Insurance Act 

The proposal to establish national insurance in this 
country was not preceded by a public inquiry of any sort. 
There was no Royal Commission or Departmental Com- 
mittee to investigate the value of national insurance, nor 
was any public report or opinion obtained from the General 
Medical Council, the Royal College of Surgeons, the Royal 
College of Physicians, the Society of Medical Officers of 
Health, or other bodies concerned with Public Health 
questions. Since the partial inquiry by the Inter-Depart- 
mental Committee on Physical Degeneration in 1904, there 
had been no general investigation into the state of Public 
Health in this country, nor into the best means of prevent- 
ing sickness. It is significant of the want of consideration 
on the most fundamental points that after passing a gigantic 
Act for the prevention and cure of sickness, the Govern- 
ment found it necessary to appoint a Committee to inquire 
into the causes of excessive sickness chiefly among women ; 
a little later it appointed a Royal Commission to inquire 
into the extent and means of preventing venereal disease in 
the community ; and still later it instituted an investiga- 
tion into the adequacy of the hospital service in this country. 
Succeeding years will probably witness public inquiries 
into many other points concerning national health, all of 
which should have been investigated before any compre- 
hensive scheme of dealing with sickness was adopted. It 
is only necessary to look at the list of Royal Commissions 
and Departmental Committees in recent years in order 
to see that on many matters of far less sweeping im- 
portance, public inquiries have preceded legislative or 


administrative action. There is little doubt that if a 
Royal Commission had been appointed to inquire into 
the state of Public Health and the steps necessary to 
improve it, a very different measure would have 
been introduced, possibly without including national in- 
surance at all. 

As far as public knowledge goes, Mr. Lloyd George 
must be regarded as the originator of the main principles 
of the Insurance Act ; and it is necessary to consider the 
significance of this fact in relation to our present methods 
of dealing with Public Health matters. We have no 
Ministry of Public Health, and no machinery by which 
Bills relating to Public Health can be submitted to expert 
opinion before their introduction into Parliament. Con- 
sequently measures involving highly scientific questions 
are introduced by persons who are quite without previous 
training or experience in Public Health work. We may 
indeed be grateful to Mr. Lloyd George for the eminent 
services he has rendered to the country in other directions, 
and the adverse criticism of his efforts in Public Health, 
which must again and again be made in this chapter, 
reflect much more upon the system, for which Parliament 
is primarily responsible, than upon him personally. When 
Mr. Lloyd George introduced the Insurance Bill he had 
not held any of the offices which would have brought him 
in touch with Public Health affairs. He had been President 
of the Board of Trade, and was still Chancellor of the 
Exchequer; but he had not been President of the Local 
Government Board, which is our nearest approach to a 
Ministry of Health, nor Secretary to the Board of Educa- 
tion, an appointment which might at least have familiarised 
him with conditions of health among children. Nor, so far 
as is publicly known, had he made any special study of 
Public Health questions or had other experience which 
would have entitled him to be regarded as an expert. 
Yet he has constantly expressed opinions upon the most 
erudite questions with a dogmatism which must astound 
many a Medical Officer of Health. 

But it is perhaps not quite accurate to say that no 
special investigation preceded the Insurance Act, for Mr. 


Lloyd George appears to have been strongly impressed by 
the national insurance scheme in Germany, and it is under- 
stood that during 1910 he spent some weeks in that country 
studying the system. At that time we were obsessed by 
belief in German science, forethought, and organisation, 
and it would be unfair to condemn imitation of German 
methods merely because our views of the German national 
character have since undergone a radical change. But the 
German system could have been condemned at that time 
and on its merits. Mr. Lloyd George's investigation must 
have been very superficial, for closer study of conditions in 
Germany would have shown that in that country national 
insurance, from the Public Health point of view, had been 
a failure just as great as it has since proved in our own. 
Germany has had a comprehensive system of national 
insurance since 1884, the benefits of which have extended 
to large groups of dependents, non-working women, and 
children ; nevertheless, the general death-rate, though it 
has fallen during recent years, has always been about 20 
per cent higher than that of England and Wales, and this in 
spite of the fact that the average age of the population 
is appreciably less than that of the population of Great 
Britain. After many years of sanatorium treatment the 
death-rate from tuberculosis in Germany was 50 per cent 
higher than in this country where no special efforts had 
been made. Yet when introducing the Bill, Mr. Lloyd 
George said : "In Germany they have done great things 
in this respect. They have established a chain of sanatoria 
all over the country, and the results are amazing. The 
number of cures that are effected is very large." x We 
adopted national insurance on the faith of statements such 
as these, and are now realising our mistake. Yet the 
merest glance at the German vital statistics would have 
shown that Germany is the very last country from which 
we can learn lessons in Public Health or Preventive 
Medicine. Not only is the general death-rate high, and 
the death-rate from tuberculosis excessive, but the infant 
mortality rate has always been very high, and between 
1901 and 1910 the deaths of infants under one year of age 

1 Parliamentary Debates, May 4, 1911. 


averaged 187 per thousand births. Bad as is the British 
record, it does not approach these appalling figures. 1 
Other countries which have adopted some form of com- 
pulsory insurance against sickness are Austria, Hungary, 
and Russia, and in none of them does the state of Public 
Health provide any testimony of the value of this principle. 
France is almost certainly the country of Europe in which 
the highest standard of general sanitation and healthy 
living prevails, and it would have afforded a much better 
model, but our Public Health authorities appear to have 
devoted little attention to its conditions. English travellers 
in France are accustomed to be somewhat scornful because 
they may find sanitary arrangements in hotels not quite 
so good as those in England ; but any disadvantages in this 
respect, or in the water-supply, are far outweighed by the 
higher standard of housing, the comparative absence of 

1 It deserves to be noted that the soundest criticisms of the proposal to intro- 
duce the German insurance scheme into this country were made by Mr. E. Lesser, 
representing the Apprenticeship and Skilled Employment Association at the 
National Conference on the Prevention of Destitution, May 30- June 2, 1911. He 
said, to quote the Report of the proceedings : " Lest they should take too optimistic 
a view of what the future of England was going to be when we had got the National 
Insurance scheme at work, he would like to call their attention to some figures from 
Germany, where, as they knew, a sickness insurance scheme had been in existence 
for twenty-five years, and invalidity for about twenty years. While admitting 
to the full the beneficial results which had been obtained in Germany from the 
operations of those two schemes, it was none the less somewhat significant that he 
was able to give them the following figures. Taking the death-rate in the German 
Empire per 1000 he found it was in 1908 as high as 18, whereas in England and 
Wales it was only 14-7; in Scotland it was 16-1 ; in Ireland 176. If they took 
the infantile mortality statistics this country compared most favourably. In the 
German Empire the death-rate of children under one year of age was 17-8 per 
cent; in England and Wales it was only 12-1 ; and in Scotland it was only 1 1 ; and 
in Ireland it was only 9-7. Then they came to other statistics as regarded mort- 
ality from certain diseases — diphtheria, measles, scarlet fever, tuberculosis of the 
lungs — and in respect of all those diseases our figures were far better than those of 
Germany. In tuberculosis of the lungs the death-rate per 100,000 inhabitants in 
Germany was 159-2, whereas in England it was only 111-7. In diphtheria the 
figures for Germany were 22-9, whereas the English figure was only 16-7. What 
did these figures show ? He thought they were entitled to say that they showed 
that thanks to our very efficient public health service, we had been enabled to keep 
ahead of Germany as regarded the health of the people without their elaborate 
insurance scheme. The point he wanted to make was that the money which we 
had been spending on improving the health of the people, on improving housing 
accommodation, and sanitation, and such like things, had been really preventive 
work because it had indirectly helped the people to live under more healthy con- 
ditions, and therefore become less likely to fall victims to sickness. To come to 
the Government insurance scheme, they were really beginning at the wrong end in 
launching a scheme of this kind. In his opinion they would be investing the 
money to better purposes if they set to build up a healthier race of children than 
they were now getting instead of spending large sums in seeking to cure the 
unhealthy and the unsound." 


slums, and the splendid open spaces which characterise so 
many of the cities of France. 

In support of his proposals Mr. Lloyd George issued 
from the Treasury a " Memorandum of Opinions of various 
Authorities in Germany " from " leading companies and 
firms in the more important German industries." These 
opinions, the writers of only two of which are named, 
consist of paragraphs written in perfectly general terms 
all extolling the benefits of the Insurance Laws. We are 
informed that they " have undoubtedly had a good influ- 
ence on the position of the working-man " ; that, " on the 
whole England would do well to adopt similar institutions 
to those which have for years been a blessing to the German 
working classes " ; that " the Insurance Laws, together 
with the increase of wages, have exercised an enormously 
beneficent influence on the health, the standard of life, 
and the efficiency of the working classes " ; and that the 
Insurance Legislation has relieved the Poor Law to a 
degree that cannot be mistaken." The paragraphs obvi- 
ously express only the employers' point of view, but there 
is one naive opinion which gives a glimpse of other views. 
The President of ' one of the largest Associations of Em- 
ployers in the iron and steel industry ' writes : " That the 
" workpeople themselves are contented is not maintained. 
" Even were the benefits under the Insurance Laws greater 
" than they are, and granted at the employers' expense, 
" there would be no permanent satisfaction of the work- 
" people's wishes ; but the reason for this lies in human 
" nature and not in the laws." The conception that human 
nature should adapt itself to law, rather than that law 
should be made to conform to human nature is perhaps 
characteristic of Germany, and may be suited to the amen- 
able people of that country ; but it has always proved a 
bad foundation for social legislation in England, and the 
Insurance Act has again exemplified the fact. 

This collection of opinions is not a scientific report. 
It presents only one side of the case ; it gives no 
statistics showing the sickness rates in Germany before 
and after the adoption of national insurance ; it contains 
no opinions from Public Health authorities and no argu- 


merit or statement which carries the smallest scientific 
weight. Regarded as a presentation of the advantages of 
national insurance in Germany it is entirely unconvincing 
and inadequate ; yet it was the sole evidence of this kind 
which was placed by the Government before the country 
previous to the passing of an Act which was to apply com- 
pulsion to one-third of the population, and cost many 
millions annually. 1 

An important difference in the objects of the two 
schemes should be noticed here. In Germany the insur- 
ance system is also a form of Poor Relief, and provides for 
necessities which are more or less covered in this country 
by the Poor Laws and the Old Age Pension Act. For 
example the Societies are required to provide death- 
benefit, old-age pensions, and, under certain conditions, 
pensions for the widow and children of a deceased insured 
person, while the hospitals undertake the treatment of 
many persons, who, in this country, would be admitted to 
the Poor Law infirmaries. 2 This aspect of German insur- 
ance is repeatedly referred to in the collection of opinions 
cited above. In the British insurance scheme all sug- 
gestion of Poor Law Relief was rigidly excluded, as shown 
by the prohibition of the use of Poor Law institutions for 
the treatment of tuberculosis and other diseases. Hence 
the success or failure of the two systems cannot be 
measured by the same test. One is designed chiefly for 
the prevention and cure of sickness, the other is in addi- 
tion admittedly a form of Poor Relief. 

But while the general principle of the British Insurance 
Act was taken from Germany, substantial modifications 
were introduced in the details, and unfortunately some of 
the best features were omitted, while some of the least 
satisfactory provisions were adopted. Perhaps the best 
feature of the German system is the excellence and com- 
pleteness of the arrangements for higher medical treatment, 
medical benefit providing treatment at hospitals, sanatoria, 

1 The Memorandum on Sickness and Invalidity Insurance in Germany issued 
in 1911 merely sets out the differences in the British and German schemes. It 
contains no examination of the advantages believed to have resulted from com- 
pulsory insurance in Germany. 

2 For further details see Medical Benefit in Germany and Denmark, I. C. Gibbon, 


convalescent homes, and forest resorts, treatment by 
specialists for affections of the eye, ear, etc., nursing, 
baths, electric treatment, milk, wine, etc., and medical and 
surgical requisites. Instead of taking this system as a 
model, we in this country have limited medical treatment 
to the barest possible minimum. On the other hand we 
took over from Germany the panel system of providing 
treatment through medical practitioners, although it had 
for years led to strife in that country between insurance 
societies and the doctors with strikes or threatenings 
of strikes by the latter, and had been shown to lead to 
malingering and other evils which have now become 
apparent here. 

Thus the Insurance Bill was introduced without any 
previous inquiry as to its need or probable effects in this 
country, without adequate investigation of the results of 
national insurance in other countries, and without the pro- 
posals having been before the country. The central prin- 
ciple was taken from a people who for many years had been 
well drilled and were accustomed to organisation, and was 
applied to a nation which, to say the least, is impatient 
of official control; and the best features of the foreign 
scheme were not copied. The Bill originated with a 
Minister who had no expert knowledge of Public Health ; 
its value in preventing sickness was assumed without 
proof on the basis of vague generalities ; and promises of 
benefit to follow were made which scientific investigation 
would have shown to be unrealisable. We may anticipate 
here the proposals which will be put forward in detail in a 
later chapter, and urge that this experience provides the 
strongest argument for the establishment of a ministry 
of Health, from which alone Government measures con- 
nected with Public Health shall originate, after they have 
been subjected to close examination and investigation by 
those who have specially studied the problems involved. 

In its passage through Parliament the Insurance Bill 
underwent many changes, some of which were of a dis- 
tinctly retrograde character, but it will be more convenient 
to indicate these when examining the provisions in detail. 
Again the absence of expert criticism was felt, and many 


matters of the greatest importance were neglected, while 
other proposals were discussed in detail which could at the 
time have been shown to be unsound and have subse- 
quently in practice proved unworkable. 

The Principles of Administration of the Act 

The Insurance Act, as it left Parliament, contained 
many unsatisfactory features ; nevertheless its very vague- 
ness and incompleteness afforded opportunity for public 
benefit, for in no previous Act had such great powers been 
given to the authorities charged with administration, and 
so many decisions of importance been left to their discretion. 
They were empowered to issue Regulations, which have 
all the force of law after they have been laid before both 
Houses of Parliament, and an address has not been pre- 
sented to His Majesty, within twenty-one days, praying 
for their annulment ; thus making the Commissioners to 
a considerable extent a legislative body. 1 In case this 
should not be sufficient, they were, for the purpose of over- 
coming initial difficulties, given powers of suspension and 
alteration of the law unprecedented in any Act of Parlia- 
ment. Clause 78 of the Act provides that — 

If any difficulty arises with respect to the constitution of 
Insurance Committees or the advisory committee or otherwise in 
bringing into operation this part of this Act, the Insurance Com- 
missioners, with the consent of the Treasury, may by order make 
any appointment and do anything which appears to them necessary 
or expedient for the establishment of such committees or for bringing 
this part of this Act into operation, and any such order may modify 
the provisions of this Act so far as may appear necessary or ex- 
pedient for carrying the order into effect. Provided that the 
Insurance Commissioners shall not exercise the powers conferred 
by this section after the first day of January nineteen hundred and 

1 In 1915 the Scottish Insurance Commissioners proposed to institute a uniform 
and comprehensive audit and issued Regulations for the purpose. When they were 
on the point of laying these before Parliament the Insurance Committee of the Burgh 
of Glasgow applied for an interdict on the ground that the proposed Regulations 
were ultra vires and an invasion of the statutory functions and right of independent 
action of the Committee. The Court held that they had no jurisdiction to entertain 
any questions as to the validity of the Regulations and dismissed the application. 


With these enormous powers even a badly-drafted Act 
could have been made to yield good results if ably adminis- 
tered ; but few will maintain that the Commissioners have, 
as a matter of fact, taken advantage of the extensive 
powers and opportunities given to them. The administra- 
tion has been allowed to assume a degree of complexity 
which baffles comprehension ; the medical service is 
notoriously inadequate and inefficient, while the Public 
Health aspects of the Act have been almost lost sight of. 
Doctors, chemists, insured persons, and society officials 
are all alike dissatisfied. On the other hand, in fairness 
to the Commissioners it must be pointed out that a prin- 
ciple was observed in their selection which must have 
hampered collective action from the beginning; and this 
point demands further examination. 

During the passage of the Insurance Bill through 
Parliament various bodies with more or less divergent 
vested interests became alarmed lest their rights and privi- 
leges should be interfered with, and much heated dis- 
cussion arose. The doctors were afraid of too much official 
control and too little remuneration ; the Friendly Societies 
were anxious to protect the position of their members ; 
the commercial insurance companies demanded admission 
into the scheme ; and representatives of women's organisa- 
tions concerned themselves with women's interests. Some 
attempt was made in the Act to unite these various in- 
terests, but Parliament left its work in this direction un- 
finished, and assigned it to the Commissioners to complete. 
For this purpose a principle was adopted in the selection of 
the Commissioners which, if not new, had certainly never 
been followed to the same extent previously, viz. the 
representation of specific interests in the administrative 
authority itself. The Medical Secretary of the British 
Medical Association, a body which had vigorously defended 
the interests of medical practitioners, was appointed 
Deputy Chairman of the English Commission ; another 
Commissioner represented the Insurance Companies ; 
another the Friendly Societies ; another who had been 
prominently associated with the interests of labour may 
be taken to represent the insured persons ; and another 


represented women's interests. The remaining members 
were the Chairman, who had had a long and distinguished 
association with educational matters, and had been Per- 
manent Secretary to the Board of Education ; another 
who had also been connected with the Board of Education ; 
the Chief Registrar of Friendly Societies who is ex officio 
a member of the Commission ; and a representative of the 
Treasury. No objection could be taken to the composi- 
tion of this body from the point of view of reconciling or 
representing the divergent interests concerned, but it is 
important to note that the course adopted involved sacri- 
ficing any idea of making the Commission authoritative in 
Public Health questions. Not one of the members, how- 
ever eminent in other directions, would claim to have had 
any special experience in Public Health administration, 
or special knowledge of its more scientific problems ; yet 
they were called upon to administer an Act which touched 
Public Health questions in every direction, and one which, 
so far from providing a fully- worked- out scheme, left to 
the discretion of the Commissioners many matters of the 
greatest importance. 

It is not surprising that under these circumstances the 
Commissioners have never regarded themselves as form- 
ing a Public Health authority. This is clear from their 
administrative actions and public utterances. They have 
devoted their energies mainly to creating the machinery 
for enforcing insurance ; they have been satisfied with mere 
names, as for instance " domiciliary benefit " in place of 
an efficient system of treating tuberculosis ; and they have 
neglected almost entirely (as we shall see when examining 
them in detail) those provisions of the Act which demanded 
scientific knowledge or were of a preventive character. 
We may note in the difference between the reports issued 
by the Insurance Commissioners and those published by 
the Local Government Board and Board of Education, 
the view which the Commissioners take of their functions. 
The Local Government Board and the Board of Education 
each issues a special report by its Chief Medical Officer 
which is not limited to administrative details, but discusses 
the work of the Department in relation to Public Health. 


The influence of that work in reducing sickness or mortality 
is pointed out ; information is given as to what has been 
done, and what it is intended to do ;| local opinions are 
quoted, and suggestions are made for improving the services 
with which the Department is concerned. Besides the 
annual medical report, special reports on scientific and 
Public Health questions are issued from time to time, 
particularly by the Local Government Board. The In- 
surance Commission has also a Chief Medical Officer, but 
he issues no medical report, and the annual report pub- 
lished by the Commissioners contains only a record of 
official transactions and administrative steps. As far as 
official sources of information are concerned, the public 
has been left entirely in the dark regarding the influence 
the National Insurance Act has had on the health of the 
people. No statistics relating to the health of insured 
persons have been issued by the Commissioners ; no steps 
have been taken to provide Insurance Committees with 
suggestions or schedules of lectures on Public Health ; and 
no leaflets have been issued on the care of health. In 
America the larger Life Insurance Companies have found 
it profitable to distribute pamphlets to their members on 
such subjects as the health of the worker, consumption, 
open-air living, housing, health of children, recreation, 
etc. But though the Commissioners have issued many 
hundreds of circulars, orders, and memoranda, not one 
of these has, up to the present, borne directly upon the 
fundamental objects of the Act, viz. the prevention and 
cure of sickness. 

Local Administration 

In local administration also the Insurance Act has 
fared badly from the Public Health point of view. The 
Bill, as originally introduced, contained the sound proposal 
for the establishment in each county and county borough 
of a " Local Health Committee." This body was charged 
with the administration of medical benefit for deposit 
contributors, and of sanatorium benefit for all persons 
entitled, but its most important function was outlined in 


the clause : " It shall consider generally the needs of the 
county or county borough with regard *to all questions of 
public health, and may make such reports and recom- 
mendations with regard thereto as it may think fit." In 
his speech on May 4, 1911, Mr. Lloyd George attached 
great importance to this duty of the Local Health Com- 
mittee, and in a Memorandum issued later he said : " The 
new authority will have an invaluable amount of statistics 
at its disposal which will enable it to locate any ' black 
spots ' in any trade or district very quickly." Unfor- 
tunately, when the administration of medical benefit was 
taken away from the Approved Societies, and assigned to 
this new local authority, the whole character of the latter 
was changed. The name " Local Health Committee " 
disappeared and was replaced by " Insurance Committee " ; 
and the duty to " consider generally the needs of the county 
or county borough with regard to all questions of public 
health " was no longer required. Insurance Committees 
still have power to make reports on the health of insured 
persons and are also required to provide lectures on health ; 
but in actual working, the time of these bodies has been so 
fully occupied by administrative details, that their Public 
Health functions have been almost entirely unexercised. 
Where Local Health Committees might have been making 
exceedingly valuable investigations into infant mortality, 
adulteration of food, bad housing, atmospheric pollution, 
prevention of tuberculosis, etc., Insurance Committees 
have spent their time in preparing and maintaining 
registers and panel lists ; in discussing such questions as 
to whether doctors may write " Rep. Mist." instead of a 
prescription; in negotiating with chemists over the cost 
of drugs and pricing prescriptions ; in keeping voluminous 
accounts ; and in deciding the maximum number of eggs 
or pints of milk which may be given under " domiciliary 
treatment " to a person in an advanced stage of phthisis. 
The change has also seriously increased the complexity 
and cost of administration. The administration of medical 
benefit was removed from Approved Societies to Insurance 
Committees in order to meet the wishes of the British 
Medical Association ; but judging from the widespread 


dissatisfaction with the present arrangement it is doubtful 
whether the doctors have really gained anything by the 
change. On the other hand the abolition of the Local 
Health Committees was undoubtedly a disastrous step so 
far as the interests of Public Health are concerned. 

Medical Benefit 

The value of the panel system from the Public Health 
point of view in providing medical attendance and treat- 
ment has already been considered, and it was shown that, 
on the whole, the standard of treatment among the insured 
class is no better than that which prevailed before the pass- 
ing of the Act. It is now necessary to consider this benefit 
in relation to the light it throws upon the methods of deal- 
ing with Public Health questions in Parliament and by the 
Administrative Departments. 

Medical benefit is defined in Section 8 of the Act as 
" Medical treatment and attendance, including the pro- 
vision of proper and sufficient medicines and such medical 
and surgical appliances as may be prescribed by regula- 
tions to be made by the Insurance Commissioners," and 
in Section 15 the Insurance Commissioners are required 
to secure that insured persons shall receive adequate 
medical attendance and treatment from the medical prac- 
titioners with whom arrangements are made. The Bill 
was some mne months in its passage through Parliament, 
but it is not possible to find in the whole course of the dis- 
cussions any clear indication of the scope of treatment, 
or of the meaning which Parliament intended to attach 
to these words. It has already been pointed out that 
specialist services and institutional treatment are by far 
the most crying needs among the working classes, and no 
system can be regarded as " adequate," in any ordinary 
sense of the term, which does not provide these. Never- 
theless, it does not appear that Parliament recognised their 
importance ; and the Act finally left the House with medical 
benefit so incompletely defined that the Commissioners 
have been able to give it a meaning which, it is safe to say, 
the majority of legislators would not have sanctioned had 


they been able to anticipate the Commissioners' inter- 
pretation. The mere fact that any doubt could arise as 
to the interpretation of so important a provision, con- 
stitutes a strong argument for assigning the drafting of 
future Public Health measures to a Ministry of Health. 

Definition of the scope of medical treatment being 
accordingly left to the Commissioners, that body proceeded 
to lay down that an insured person is entitled only to 
" such treatment as is of a kind which can consistently 
with the best interests of the patient be properly under- 
taken by a practitioner of ordinary competence and skill," 
and it may be recalled that these words have now the 
force of an Act of Parliament. We will consider this 
definition from its Public Health and legal aspects sepa- 

From the Public Health point of view the decision was 
disastrous. The Regulations did not even prescribe the 
highest standard of general practice, and at a stroke of 
the pen all opportunity of providing consultant services, 
institutional treatment, surgical procedure, and nursing 
was lost. It is true that when the extra Parliamentary 
grant for the doctors was provided, a half-hearted attempt 
was made to couple this with provision of facilities for 
laboratory examinations, but no such facilities were in 
fact provided. The system has given panel practitioners 
an opportunity of charging insured persons for services 
which they held were outside the scope of their contracts, 
and it has led to disputes as to what services might be 
regarded as within the scope of a practitioner of ordinary 
competence and skill. To settle these disputes the Com- 
missioners have adopted the remarkable course of appoint- 
ing an outside body of Referees to whom the differences 
are submitted ; thus declining responsibility for the inter- 
pretation of a definition which they themselves had framed. 

From the legal point of view it is open to doubt whether 
the action of the Commissioners can be justified. Although 
the word " adequate " is not defined in the Insurance Act, 
there are several arguments which tend to show that it 
does not bear the exceedingly narrow meaning given to it 
by the Commissioners. We may for example refer to 



another Act of Parliament in which the same word is used, 
and note the meaning which has been given to it by the 
Courts. Section 12 of the Children Act of 1908 provides 
that " a parent or other person legally liable to maintain 
a child or young person shall be deemed to have neglected 
him in a manner likely to cause injury to his health if he 
fails to provide adequate food, clothing, medical aid, or 
lodging for the child or young person." Under this clause 
parents have been convicted for failing to have defective 
eyesight in their children treated, and have been required 
to provide spectacles for them. A parent has also been 
prosecuted and convicted for refusing to have an operation 
for adenoids performed on his daughter. 1 If these actions 
by the Courts are legally correct, the words " adequate 
medical aid " in the Children Act clearly include at least 
special treatment of the eye and throat, and it is difficult 
to see why the words " adequate medical attendance and 
treatment " in the Insurance Act should bear any lesser 

The Insurance Act itself contains a schedule of addi- 
tional benefits which Approved Societies may give when 
their funds permit. These benefits include medical treat- 
ment and attendance for dependents of insured persons ; 
payment of the cost of dental treatment ; increase of sick- 
ness or maternity benefit ; assistance during convalescence ; 
payment of superannuation allowances ; repayment of the 
whole or part of contributions, etc., etc. They do not 
include any power to provide the services of consultants, 
surgeons, or gynaecologists, or any form of institutional 
treatment except for convalescents. If these services are 
not included in medical benefit, then they cannot be pro- 
vided under the Insurance Act at all. It is surely reason- 
able to suppose that the Act provides a complete medical 
service for insured persons, before benefits are extended 
to persons outside the Act, or contributions are reduced ; 
if not it becomes simply ludicrous. 

There is a curious admission in the " Conditions of 
Service for Practitioners " laid down by the Commissioners, 
which indicates that the Commissioners themselves were 

1 Report of Chief Medical Officer to Board of Education, 1912. 


not satisfied that the panel system was adequate. Clause 2 
of these conditions runs as follows : — 

Where the condition of the patient is such as to require services 
beyond the competence of an ordinary practitioner, the practitioner 
shall advise the patient as to the steps which should be taken in 
order to obtain such treatment as his condition may require. 

It is clear therefore that the Commissioners antici- 
pated that conditions would occur among insured persons 
for which the panel service would not provide adequate 
treatment, and in securing that these persons should receive 
only " advice " instead of the treatment their condition 
demanded, the Commissioners were not carrying out the 
intentions of the Act. 

These arguments are reinforced by Mr. Lloyd George's 
own interpretation of the powers of the Act. In his speech 
to the Advisory Committee on January 2, 1913, more than 
a year after the passing of the Act, he said, speaking of a 
salaried service : — 

I will show you what this means. We thought that we should 
have had an opportunity of setting up a service of this kind at 
Bradford. Bradford was very anxious for it. There was a real 
demand from the working classes for it. The doctors were very 
very obdurate, and we worked up our plan. Now the doctors came 
in in time ; and so there is no salaried service at Bradford. But I 
will just show you how it would have worked out within the money 
available. You have 100,000 insured persons in Bradford. You 
have 7s. or 7s. 6d. as the case may be. That depends upon the 
debateable 6d. for drugs. If you make it 7s. that is £35,000. If 
you make it 7s. 6d. that is £37,500. We proposed to engage 50 
doctors at £500 a year. . Then we thought it would be necessary to 
have a certain number of consultants and specialist surgeons, so 
that it was proposed the service should include three specialist 
surgeons, one of them being an oculist, and that at the head of the 
service there should be a consulting physician, a superintendent at a 
salary of £1200 a year. The specialist surgeons were to receive 
£1000 a year. With the remaining £8000 we proposed to get other 
assistance for the doctors. We proposed that there should be 50 
nurses. You will find that still there would be something to spare, 
especially on the 7s. 6d. basis, for the provision of aids to exact 
diagnosis which pathology and bacteriology have placed at the 
disposal of modern medical science. 

For the moment we are not concerned with the reasons 


why this service was not established. The important 
point to notice is that the authorities had already decided 
to establish it, and had been able to come to this decision 
without going to Parliament for further powers. It was 
clearly at that time their conception of what constituted 
an ' adequate ' service. If this service could not legally 
be provided, then Mr. Lloyd George's speech was mere 
' bluff.' On the other hand, if it is the correct interpreta- 
tion of the Act, then for four years the Commissioners have 
not been fulfilling their legal obligations. 

On the other side of this question there are two points 
which in fairness to the Commissioners must be noticed. 
In the first place, the statement has been freely made (for 
instance in the Fabian Society's Keport) that since Mr. 
Lloyd George had been obliged to give the doctors all the 
money available under the Act, as well as an additional 
1| millions by a special Parliamentary grant, there was 
nothing left to pay for consultants and special services. 
If this statement is correct, it reveals a curious state of 
affairs. It means that Parliament passes an Act intend- 
ing that certain things shall be done; and the persons 
appointed to carry out this Act find that there are not 
sufficient funds for the purpose. Instead of reporting to 
Parliament that they have been asked to undertake an 
impossible task, and leaving the legislature to decide 
whether the things proposed should not be done, or what 
part of them should not be done, or whether additional 
funds should be provided to carry out the whole pro- 
gramme, the administrators themselves, or the minister 
responsible for the Department, decide which part of the 
duties assigned to them shall be done, and which part 
shall be disregarded. This is of course the complete sub- 
stitution of bureaucracy for Parliamentary Government. 

The second point which might be urged in defence of 
the course taken by the Commissioners is, that the Act 
requires them in the first place to arrange for a list of 
practitioners in each district who will undertake treatment 
of insured persons, every qualified practitioner having the 
right to be included in such lists. But there is an im- 
portant proviso to these clauses which runs : — 


Provided that, if the Insurance Commissioners are satisfied after 
inquiry that the practitioners included in any list are not such 
as to secure an adequate medical service in any area, they may 
dispense with the necessity of the adoption of such system as afore- 
said as respects that area, and authorise the Committee to make such 
other arrangements as the Commissioners may approve ; or the 
Commissioners may themselves make such arrangements as they 
think fit, or may suspend the right to medical benefit in respect of 
any insured persons in the area for such period as they think fit, 
and pay to each such person a sum equal to the estimated cost of 
his medical benefit during that period. 

But while the Commissioners were thus bound to 
initiate the panel system, there does not seem to be any 
reason in the Act why they should not have strengthened 
it by appointing to each panel a staff of consultants and 
specialists ; for the word ' practitioner ' includes specialists 
as well as general practitioners. It has been argued against 
this view that the Act only entitles an insured person to 
the services of one medical man ; but this limitation clearly 
only applies to his right to choose one medical practitioner 
from the panel list. There is no prohibition against his 
receiving additional attendance from a consultant, though 
he has not the right to select this consultant. As a matter 
of fact, the Commissioners do appear to contemplate an in- 
sured person receiving services from two doctors simultane- 
ously, for in a few districts where the system of ' payment 
by attendance ' has been adopted by the panel doctors, 
instead of payment by capitation fee, the list of services 
officially recognised by the Commissioners as those for 
which payment can be made includes : " Surgical opera- 
tion requiring local or general anesthetic," and " Adminis- 
tration of general anaesthetic." It can hardly be supposed 
that the Commissioners intended one and the same person 
to perform an operation and give a general anaesthetic. 
Moreover, the first series of Regulations issued by the 
Commissioners in October 1912 contained in the list of 
services entitling to payment, " Consultation : (a) for the 
ordinary attendant ; (b) for the consultant (if himself a 
practitioner on the panel)." It is significant that this 
entry disappeared in later issues of the Regulations. 

But though the Commissioners are empowered to make 


other arrangements where the service is inadequate, they 
have never made any public inquiry into its efficiency. 
Previous to the middle of 1914, when the outbreak of war 
rendered such a course impracticable, the Commissioners 
could at any time have acquainted themselves with the 
conditions in poor-class districts, the overcrowded waiting- 
rooms, the ' lock-up ' surgeries, the hasty and inefficient 
attendance, and other evils which have been so fully in- 
vestigated and made known by independent bodies. With 
their extensive powers they could have strengthened the 
service in the worst districts, and could even have gone 
the length of establishing a whole-time medical service if 
necessary. It is more and more frequently urged that the 
present panel system should be supplanted by a national 
medical service. The arguments for and against this pro- 
posal will be considered in a later chapter, but here it may 
be noted that as far as insured persons are concerned, no 
further legislation is required for this purpose, and that 
the Commissioners can not only establish such a service, 
but are actually bound to improve the present system 
if they find it inadequate ; while from the estimates given 
by Mr. Lloyd George in regard to Bradford, it may be 
inferred that the present funds are ample to provide for 
this service. 

In a letter to the Times of January 3, 1912, Sir Clifford 
Allbutt said : " In his Insurance Bill the Chancellor was 
content with an antiquated notion of medicine and of 
medical service ; he took for granted, without inquiry, a 
notion built of some vague knowledge of village clubs, 
and of the old-fashioned vade mecum way of doctoring. 
This is, ' For such and such a disease such and such a drug ; 
take the mixture, drink it regularly, and get well if Nature 
will let you.' And if our people have ceased to check the 
doctor's bill by the pill-boxes, bottles, and pots on the 
shelf, even Cabinet Ministers have not escaped from this 
ancient habit of thought." 

This conception of medical treatment has apparently 
governed the administration of the Act, and no effort 
seems to have been made to rise above the standard of 
treatment among the old Friendly Societies, or even to 


investigate the needs of the community. Nor is the 
insufficiency of the service the only evil. The panel 
system has increased the element of commercialism in 
medical practice ; it has done nothing to strengthen the 
interest of the doctor in the scientific side of his pro- 
fession ; it has led to considerable ill-feeling between non- 
panel and panel practitioners ; and it has brought about 
the evil foreseen from the first, that of establishing 
a distinction between the ' rich man's ' and the ' poor 
man's ' doctor. 

The Supply of Drugs 

The history of the drug supply under the Insurance 
Act affords some interesting lessons in official muddle and 
extravagance. Out of every nine shillings paid for medical 
benefit, approximately two shillings represent the cost 
of drugs and medicines. For 14 million insured persons, 
therefore, the total annual cost is £1,400,000, and this 
is exclusive of certain supplementary sums and cost of 
administration. Previous to the Insurance Act it was the 
custom in working-class practice for doctors to dispense 
their own medicines, but Mr. Lloyd George assigned this 
work to chemists, for the reason which he gave in the House 
of Commons, that ' there ought to be no inducement for 
underpaid doctors to take it out in drugs.' This step 
substantially increased the expense. The special in- 
vestigation made later by Sir William Plender for the 
Government, showed that the average cost of drugs to 
doctors practising in towns, including dispensers' fees, etc., 
was 5d. per head of the population. In a series of Friendly 
Society Institutes, with an aggregate membership of 
75,500, the average cost of drugs, including bandages, 
dispensers' salaries, etc., was lOd. per member. It is 
clear, therefore, that the mere change of system involved 
an additional cost of at least £700,000 annually. It is 
probable that the Government did not even know the cost 
of drugs, when supplied by doctors, until Sir William 
Plender made his inquiry nearly a year after the Insur- 
ance Act had been passed. 


We must now note how far this costly change of system 
has achieved its object, viz. that of improving the quality 
of drugs supplied. The Government offered the chemists 
a capitation fee of Is. 6d. per insured person for the supply 
of drugs. The chemists, through the Pharmaceutical 
Society, expressed the view that this amount was in- 
sufficient. Eventually the question was settled by the 
establishment of the ' floating sixpence,' an arrangement 
which was described by Mr. Lloyd George as follows : 
' The doctor is the only person we can trust to check 
' drugs. We are going to leave that 6d. there between the 
' doctor and the chemist. It will provide £320,000. That 
' £320,000 will be available if the drug bill exceeds the 
' Is. 6d. provided ; and where it does not exceed that 
' Is. 6d. it will be available for the doctor. That is not the 
' case with regard to the Is. 6d. I want to make it clear 
' that, at any rate up to Is. 6d., there ought to be no induce- 
' ment to the doctor to cut down the drugs. We want the 
' best drugs available in the market for the treatment of 
•' the industrial population of this country, in the interests 
' of the State as well as for humanitarian reasons, and we 
' realise that it mil be necessary to have at least Is. 6d. 
' available for the provision of drugs." 1 Thus, after taking 
away the dispensing from the doctors because they could 
not be trusted to supply good drugs, Mr. Lloyd George 
finds, eighteen months later, that they are the only persons 
whom he can trust to check drugs ; and while reiterating 
his demand for the best drugs in the interests of the State, 
he gives the doctors a direct financial interest in prescribing 
the minimum amounts and cheapest qualities. 

But soon pressure was brought to bear from other 
directions to reduce the cost of drugs. The Commissioners 
gave tacit assent to a tariff which was drawn up by the 
Pharmaceutical Society, and at the end of 1913, and still 
more at the end of 1914, the fund, even with the aid of the 
' floating sixpence,' was insufficient in many localities to 
pay the chemists in full, and their bills were accordingly 
discounted 10, 20, and even 30 per cent. This gave rise 
to great dissatisfaction among the chemists, and to meet 

1 Supplement to British Medical Journal, October 26, 1912. 


their complaints efforts were made by the Insurance 
Commissioners and Committees to reduce the supply and 
cost of drugs. All thought of providing only the ' best ' 
drugs went to the winds. Expensive drugs were eliminated 
from the lists, ' stock ' mixtures were introduced, tap- 
water was substituted for distilled water, and finally a 
system of investigating practitioners' prescriptions was 
established in order to put a stop to what was termed 
' excessive prescribing.' Many doctors who in May 1911 
were to be under no restrictions in supplying medicines 
were now required to attend before tribunals to justify 
their orders for medicines in particular cases, and were 
liable to surcharge. 1 

Under these circumstances it is not surprising that 
there have been numerous complaints as to the quality of 
drugs supplied and of faulty dispensing by panel chemists. 
For instance, in Salford, out of nineteen samples of 
mixtures dispensed under the Insurance Act which were 
analysed by the borough chemist, eight were found to be 
unsatisfactory. In Birmingham, nineteen prescriptions 
by panel doctors ordering a mixture and a paint were 
analysed, and sixteen samples of medicine from twelve 
chemists were found not to have been properly dispensed. 
In an inquiry by the Insurance Commissioners in Man- 
chester, it was shown that among 17,000 prescriptions dis- 
pensed by one firm, 3000 were prima facie irregular. A 
doctor who gave evidence said that he had examined 3194 
prescriptions signed by him, and about 2000 contained 
improper alterations. It would appear therefore that 
insured persons are at least no better off than they would 
have been if dispensing had been left in the hands of the 

1 The following extracts from Memo. No. 648/1. C, issued by the Scottish Com- 
missioners in July 1915, illustrate the official pressure which was brought to bear 
upon the doctors : — 

" For the guidance of practitioners it is suggested that every prescription should 
in the meantime conform to the following conditions : 

"(1) The quantity prescribed at one time should be strictly limited. 

" (2) The drugs employed should be, ceteris paribus, the least expensive of 
their class. 

" (3) Flavouring agents should be reduced to a minimum, and the more ex- 
pensive, where a less costly equivalent is not available, should be restricted to 
cases in which therapeutic benefit would not be obtained without their use. 

" (4) Drugs should be put up in the least expensive form consistent with the 
requirements of the case." 


doctors. Indeed it is not clear that the charge that 
doctors were wont to ' take it out in drugs ' is, as a 
general statement, substantially true. In country districts 
where no chemist is available, panel practitioners are 
allowed to do dispensing, but, so far as the writer is aware, 
complaints against these doctors have not included any of 
supplying bad medicines. 

Early in 1915 the Commissioners seem to have come to 
the conclusion that the original drug tariff drawn up by 
the Pharmaceutical Society, which without adequate in- 
vestigation they had allowed to form the basis of contracts 
between Insurance Committees and chemists all over the 
country, might be revised ; and accordingly a Depart- 
mental Committee was appointed for the purpose, and 
issued a report in September. This report showed that 
the tariff was full of anomalies and defects, and that 
although occasionally imposing hardships on chemists, 
it yielded high profits on a large number of drugs and pre- 
scriptions. A new tariff based upon commercial principles 
was drawn up by the Committee, and came into force in 
1916. Thus four years after the Insurance Act was 
passed, the supply of drugs was for the first time placed 
upon a business footing. But even now the muddle is 
not at an end. The ' floating sixpence ' is still retained, 
and since its division between the chemists and the doctors 
was based upon the old tariff, this tariff must be main- 
tained for the purpose ; thus in every district the cost of 
drugs must be determined twice over and on two separate 

The system of supplying drugs under the Insurance 
Act has involved an immense expenditure of labour and 
time. A glance at a few agenda of Insurance Committees 
will show that chemists' accounts and questions of drug 
supply form one of the matters most frequently under 
consideration. The checking and pricing of the millions 
of prescriptions has entailed the appointment of numerous 
salaried accountants with staffs of checkers and sorters. 
The Insurance Commissioners have issued sheaves of reports 
and circulars, including a ' Keady Reckoner ' for arriving 
at the prices of ingredients of prescriptions to the second 


place of decimals. 1 Numerous Committees of Inquiry 
nave been constituted by chemists, doctors, and officials, 
and voluminous reports have been issued. On the other 
hand, an additional shilling to the doctor's capitation fee 
for dispensing would have paid the doctors very well 
in view of Sir William Plender's report, would have 
saved the country half the cost of the present system, 
secured at least as good a supply of drugs, and averted 
endless dissatisfaction and confusion. The tragedy of this 
waste becomes all the more apparent when we realise how 
utterly disproportionate is the benefit to the health of 
insured persons derived from the whole system. 

The duty of drawing up a schedule of medical and 
surgical appliances for insured persons was also left to 
the Commissioners. The list consists of ordinary dressings 
and ice-bags, splints and catheters. Other appliances are 
however urgently needed, particularly trusses, which 
many of the Friendly Societies formerly supplied free of 
charge. The cost of these would probably be covered 
many times over by their enabling persons sooner to 
resume their work. 

Sanatorium Benefit 

This benefit is denned in the Act as : " Treatment in 
sanatoria or other institutions or otherwise when suffering 
from tuberculosis or such other diseases as the Local 
Government Board with the approval of the Treasury 
may appoint." To meet the cost, Parliament provided a 
capital sum of one and a half millions for grants in aid to 
sanatoria and similar institutions, and an annual contri- 
bution of Is. 3d. per insured person, equivalent to an 
annual sum of one million. Sanatorium benefit may be 
extended to dependents of insured persons, and if in any 

1 The British Medical Journal of January 29, 1916,criticising this Ready Reckoner, 
says : " It occupies twenty-four foolscap pages of figures with two pages of de- 
scription as to their use, and a page is also devoted to an account of the twenty- 
three varieties of dispensing fees, which will probably be a source of endless questions 
and disputes. The Ready Reckoner will undoubtedly save much trouble to the 
pricing staffs, with a consequent saving of expense, but one cannot help feeling 
that in the years to come it will be regarded, with the cumbrous system for which 
it stands, as a curious relic of antiquity." 


district the annual amount available to meet the cost is 
insufficient, the deficit may be made good by the county 
or county borough paying one half, and the Treasury pay- 
ing the other half. 

This benefit also has in practice proved very different 
from what appears to have been intended by Parliament. 
Throughout the debates the importance of providing 
sanatoria for the tuberculous was insisted upon, and it 
was clearly for this purpose that the money was intended 
mainly to be spent. But when Mr. Lloyd George made 
the financial arrangements with the doctors, the scheme 
was widely altered. " Domiciliary treatment," a term 
which does not occur in the Act and was not heard in 
the debates, was invented, and 6d. was taken from the 
Is. 3d. to pay the doctors for this treatment. Now domi- 
ciliary treatment is simply ordinary medical treatment by 
a general practitioner, with the addition of a small weekly 
allowance of milk, eggs, or cod-liver oil, and sometimes 
the loan of a shelter to be erected in the back garden. At 
the present time the majority of the tuberculous insured 
persons are receiving their sanatorium benefit in this form. 
The funds for the maintenance of sanatoria have been 
raided to the extent of 40 per cent ; the ' chain of sana- 
toria throughout the country ' is still far from complete, 
and many persons whose condition demands institutional 
treatment are unable to obtain admission into sanatoria 
or other institutions. Legal justification for this course 
is found in the words ' or otherwise ' in the Act ; but in 
reality it was simply a means of transferring a sum of 
money from one fund to another, and it illustrates again 
the extent to which an Administrative Department or a 
Minister can alter an Act of Parliament. Had the legis- 
lature been aware that instead of the great benefits pro- 
mised being realised, two-fifths of the sum provided for 
the maintenance of sanatoria would be allocated to an 
entirely different and inferior form of treatment, it seems 
very doubtful whether it would have agreed to the scheme. 

Dispensary treatment, a form of treatment which brings 
the patient under the cognisance of an expert tuberculosis 
officer, has undoubtedly proved more useful, mainly for 


purposes of diagnosis. Sanatorium treatment requires 
detailed consideration. 

Sanatorium treatment of tuberculosis arose from the 
observed value of breathing pure air in the treatment of 
phthisis, and was first developed on an extensive scale in 
Germany and the United States. The treatment consists 
essentially in spending as much time in the open air as 
possible, together with adequate and appropriate diet, 
suitable exercise, rest, and medical care. During early 
years there was a tendency to exaggerate the value of the 
treatment, almost certain cure being promised provided 
the disease was not too far advanced. Later experience 
modified these sanguine expectations, but nevertheless 
established that in sanatorium treatment we had a valu- 
able means of combating tuberculosis in appropriate cases. 
It was found that after a residence of from six to eighteen 
months in a sanatorium, the disease might be permanently 
arrested in some persons who were not suffering from it in 
an advanced form, while others were substantially bene- 
fited and their lives prolonged, even if they eventually 
succumbed to the malady. But it was one thing to improve 
patients while under treatment, and another to maintain 
that improvement after they left the sanatorium. It 
soon became clear that discharged patients, if they are 
to benefit permanently by their treatment, must continue 
to live under conditions approximating to those within 
the sanatorium, i.e. lead an out-door life in pure country 
air, with abundance of nourishing food and perfectly 
hygienic surroundings. Patients who go back to sedentary 
occupations in close, ill- ventilated rooms or factories in a 
crowded and smoky city, are almost certain to suffer a 
recurrence of the disease. 

The earlier optimistic beliefs in the efficacy of sana- 
torium treatment were drawn mainly from the experience 
of paying institutions opened for the wealthier classes. 
These are, however, just the people among whom the best 
results might be expected, since they are in a position to 
make the necessary modifications in their form of living 
and some spend months of each year in health resorts. To 
suppose that anything like such good results would follow 


the provision of sanatorium treatment for an industrial 
working-class population was to ignore wholly the neces- 
sities demanded after the actual period of treatment. Yet 
this was done under the Insurance Act. Insured persons 
suffering from tuberculosis have received treatment in 
sanatoria for some months, though frequently for too 
short a period to derive the full advantage, have gained 
markedly in health, and have on their discharge figured 
in the statistics as ' cured ' or ' improved.' They have 
then gone back to their old environment, and after a 
longer or shorter period the disease has reasserted itself. 
The opinion is now widely held among Tuberculosis Officers 
and Medical Officers of Health that sanatorium treatment 
is of comparatively little value among the working classes. 
In support of this statement the following opinions of 
persons specially qualified to judge may be quoted : — 

Dr. Squire, the adviser on sanatorium benefit to the London 
Insurance Committee, has said in a report : "In chronic cases — 
where the disease though not active is still smouldering — cure or 
complete arrest is improbable, and the most that can be anticipated 
from institutional treatment is such improvement in general health 
as to allow of a temporary return to work, the duration of which 
will be largely conditioned by the nature of the employment and 
the hygienic environment to which the individual returns on 
leaving the institution. Thus, patients returning to a poverty- 
stricken home are likely — or indeed almost certain — to break down 
soon after their return, and the benefit derived from the treatment 
is of little practical value. Economically the benefit derived is not 
worth the expenditure on the treatment. A few weeks' stay in an 
institution from which they return to conditions under which they 
quickly revert to their previous state of ill-health is of little practical 
utility either to themselves or to the community." 

At a meeting of the Northern Branch of the Society of Medical 
Officers of Health, December 1915, Dr. Dickinson, the Tuberculosis 
Officer for Newcastle, said : " One is bound to confess that sana- 
torium treatment of the phthisical poor has never come up to expecta- 
tions, and practically never results in the cure of open tuberculosis. 
... In my experience the results are uniformly bad amongst children 
who have tubercle bacilli in their sputum." Dr. Hemborough, the 
County M.O.H. for Northumberland, considered that sanatorium 
patients would derive little permanent benefit from the treatment 
so long as they had to return to the bad home-conditions under 
which so many of them lived. Dr. Taylor, M.O.H. for Chester-le- 


Street, said that it was useless to treat a man in a sanatorium, where 
he lived under ideal conditions, and then discharge him to an ill- 
ventilated, insanitary home, where the family convenience was a 
bar to everything he had been taught. Dr. Renney, M.O.H. for 
Sunderland, considered that ill - ventilated and closely crowded 
dwellings were the great unit in the spread of infection. The poorer 
sanatorium patients almost invariably declined after returning home. 
Dr. A. Smith, M.O.H. for Whickham, said he had latterly come 
to regard the infectiousness of phthisis as over-emphasised. . . . 
Notwithstanding all that had been done under the Insurance Act 
and by the tuberculosis dispensary, the death-rate from phthisis in 
his district was markedly higher than previously. Dr. Allen, the 
President of the Society, was disappointed with the results of 
sanatorium treatment. Poverty and insanitary home-conditions 
were all against sanatorium patients after their discharge. Not one 
speaker at this meeting spoke in favour of sanatorium treatment 
among the working classes. 

Dr. Guy, the Tuberculosis Officer for Edinburgh, said in a recent 
report : " The housing question is one of the vital points in dealing 
with the problem of tuberculosis. Hitherto we have heard a great 
deal about sanatoria, etc., and too little about these houses. The 
disease should be attacked there ; and my opinion inclines to the 
belief that if all the money which is at present being poured out 
on sanatoria had been spent on an improvement of housing condi- 
tions, the results would certainly not have been less satisfactory." 

Dr. Williamson, the M.O.H. for Edinburgh, has said : " Sana- 
toria and dispensaries are not of themselves likely to be attended 
by markedly beneficial results in the absence of other definite 
preventive measures." 

Dr. J. E. Esslement, Medical Superintendent of the Home 
Sanatorium, Bournemouth, after pointing out the advantages of 
sanatorium treatment, at a congress on tuberculosis in 1914, 
said that sanatorium treatment, however, had great limitations. 
As a means of stamping out tuberculosis the great expectations 
with regard to its efficacy had not been realised. It was expensive. 
Treatment could seldom be carried out for longer than three or six 
months. Cures were seldom complete, and little was accomplished 
in preventing the spread of infection in the community. In Ger- 
many in 1910 there were 800,000 infectious cases of tuberculosis ; 
41,262 received sanatorium treatment, but of these only 3300 were 
rendered non-infectious. 

Statistics relating to the condition of patients on dis- 
charge from sanatoria are of little use as a means of measur- 
ing the value of the treatment, since the terms employed, 
' disease arrested,' ' condition improved,' ' fit for work,' 


etc., are unavoidably indefinite, and give no indication 
of the state of patients one year and two years after dis- 
charge. When we examine the reports of individual 
sanatoria which do give this information, the results are 
often melancholy. For instance, from a report by the 
Clerk of the Insurance Committee of the County of Ayr, 
we learn that of 237 persons who were sent in 1914 and 
1915 to sanatoria, 69, or nearly one-third, were dead by the 
middle of 1916. Yet these appear to have been cases 
selected as favourable for the treatment, since others were 
sent to hospitals or infirmaries, or were refused benefit 
on account of the disease being too far advanced. Of 49 
persons treated in 1915 in the Paisley sanatorium, 12 
were discharged improved, 10 not improved, 3 left, 15 
died, and 9 were still under treatment. 

When we examine the mortality returns for the whole 
country, which should reflect the influence not only of 
sanatorium treatment but also of tuberculosis dispens- 
aries and domiciliary treatment, we find little encourage- 
ment for the belief that sanatorium benefit has had any 
appreciable effect in reducing tuberculosis. The death- 
rates from phthisis in England and Wales were : 1017 per 
million in 1912; 989 in 1913; and 1022 in 1914. While 
for 1915, 1 admittedly under exceptional circumstances, 
the rate, 1140, was higher than in any year since 1907. 

While admitting that a certain number of persons have 
derived benefit from residence in sanatoria, and a larger 
number have received care and attention which they could 
not have obtained at home, there is no doubt that sana- 
torium benefit as a means of preventing and curing tuber- 
culosis has been a great and costly failure. It was not 
suitable for application to the working classes ; it does 
nothing to destroy the environmental causes of the dis- 
ease ; it has led to the outpouring of large sums of money 
which could have been much better employed in clearing 
overcrowded areas ; and, saddest of all, it has created 

1 At the time of writing, the Report of the Registrar-General for 1915 is not 
published. The death-rate from phthisis, which relates only to the civil popula- 
tion, is however given in the Report of the Chief Medical Officer to the Board of 
Education. The increase though highest at military ages is not confined to those 


hopes in the minds of many thousands of poor persons torn 
by disease, which have not been and could not have been 

For the purposes of this book it is necessary to examine 
how this great mistake came to be made, and here aga'in 
we are bound to recognise the effect of Mr. Lloyd George's 
personal influence and optimism. On July 7, 1911, he said 
in the House of Commons : — 

If this experiment is a success, and it becomes perfectly evident 
that it is effectively stamping out consumption, it will be a great 
mistake for the State not to face any liability within reason in order 
to effectively stamp out this scourge altogether. ... I am a believer 
in sanatoriums as my hon. friends are ; but it is an experiment. 
There are doctors in this country of great experience who are not 
quite so confident as to this being the best method of stamping out 
consumption. I think it is worth while making the experiment, 
and it is worth while making it well. . . . Some one suggested that 
the danger was that this provision will be for the better class. As a 
matter of fact, it is for the wretched people who have no homes 
where they can be cured that these sanatoriums will be most use- 
ful. ... I invite the House to try the experiment on this very con- 
siderable scale — £1,500,000 towards building and £1,000,000 towards 
maintaining them. 

On July 12, 1911, Mr. Lloyd George said :— 

A good many remedies which after years of struggle have 
managed to secure the approval of the profession have come to 
stay, and the case of sanatoria is a case of that kind. It is not 
something which has been suggested within the last few years. It 
is something which was suggested a good many years ago — I 
forget how many ; but I am not sure it is not forty or fifty years ago 
when an English doctor tried the experiment. It has been a long 
experiment, and it has gone through the same stages as every other 
successful experiment. It has taken very many years to convert 
the faculty, and it is only because the experiments extending over a 
good many years have been a success that doctors have been at 
last convinced that there is a good deal to be said for it. I do not 
therefore put it in the same category as a sort of fashionable craze. 
It is something tried and tested by the most severe test of all, the 
test of experience extending over something like two generations. 

It may be noted that the only experiment at that time 
made on a national scale was in Germany, the results 
of which had been anything but encouraging. 


The right hon. gentleman quoted in the debate the ex- 
perience of the Hearts of Oak sanatorium and the Post Office 
sanatorium. But in these two together the total number 
of cases tabulated was only 226 ; the results were described 
under the vague headings ' disease arrested,' ' improved,' 
' unimproved ' ; and the information related to condition 
on discharge. Nevertheless, on these utterly inadequate 
data, Mr. Lloyd George committed himself to the general 
statement : " This shows that experiments in this country 
have been a very considerable success." 

Mr. Lloyd George was not left uninformed that much 
expert opinion was against his views. In the course of 
the debate, Mr. Walter Long, an ex-President of the Local 
Government Board, said : — 

I can find no reliable evidence to show that treatment in 
sanatoria has been really effective. . . . The results so far as real 
cures are concerned have so far been very moderate. . . . Messrs. 
Elderton and Perry, of the Department of Applied Mathematics, 
University College, as a result of their study of the " Mortality of 
the Tuberculous and Sanatorium Treatment," arrived at the follow- 
ing conclusions : (1) the mortality of tuberculous patients treated 
in sanatoria, even when the disease is taken in an incipient stage, 
is four times as heavy as in the general population, and (2) that 
the mortality of the apparently cured (sanatorium) is twice as heavy. 

Dr. Hillier quoted Professor Koch that, " neither in 
Germany nor in any other country had the really necessary 
measures for preventing the disease been taken," and added: 

. . . any proposal which merely regards sanatoria as places for 
the treatment of early phthisis, or places where advanced cases may 
be treated and then allowed to go back to the family, really fails 
to achieve the first requirement of any great preventive measure. 

Mr. Arthur Lynch said : — 

I wish to speak more in regard to the importance of research. . . . 
You may spend millions of money upon sanatoria, and ten years 
afterwards when you take a retrospect of what has been accom- 
plished the answer may be almost nothing. . . . There is a powerful 
school of medicine, comprising, broadly, those who are in the fore- 
front of bacteriological work, who doubt whether much advantage 
scientifically is derived from sanatoria if limited to the expectant 
treatment. . . . Before sitting down I should like to propose the 
impossible, that is, I think all this is a case for special examination 
by a special committee. 


Dr. Esmonde said : — 

I would ask the Chancellor of the Exchequer not to spend his 
million and a half on large buildings which may be utterly and 
completely useless within a few years, but to spend a good deal of 
it in research. . . . Experience of the plan of sanatoria is that a 
person goes to one of these institutions believing that he is going 
to get well because he has got the disease in the first stage ; he 
comes back to his home and after a very short time dies. We have 
really nothing definite to go upon, and any man in general practice 
in this country during the last twenty-five years must be deeply 
despondent at the results which have been achieved. 

Other opinions might be quoted, but these are sufficient 
to show that adverse criticism now of sanatorium benefit 
is not an instance of ' being wise after the event.' Medical 
and expert opinion in 1911 held that sanatorium treat- 
ment was a useful measure in certain selected cases, among 
people who could continue to live under hygienic sur- 
roundings, but it never endorsed the sweeping statements 
and proposals of the Chancellor of the Exchequer ; and 
those members of the House of Commons best qualified 
to judge pleaded for further investigation. 

It was however apparently German experience which 
most influenced Mr. Lloyd George, and he quoted in detail 
certain German statistics as justification for his views. 
But reading his speeches carefully, it is difficult not to 
come to the conclusion that he had misunderstood these 
statistics, and he appears equally to have misled those he 
was addressing. The statistics with which he made most 
play were those which showed the proportion of persons 
discharged from sanatoria as able to return to work. But 
he did not state that German authorities use those words 
to mean not only persons fully capable of working, but 
also those capable of working in the sense of the sickness 
insurance law, i.e. possessing one-third of the normal capa- 
bility ; and it seems clear that they were interpreted by 
the House of Commons as meaning persons cured of the 
disease. The statistics showing the proportions discharged 
as ' cured,' ' improved,' etc., give a much less favourable 
picture, but Mr. Lloyd George did not refer to these. 
German writers themselves have exposed the hollowness 


of the statistics relating to capacity for work. The Fiirsor- 

gestellen (Assistance Centres) for phthisical patients have 

found that a large percentage of patients discharged from 

sanatoria with the certificate ' fully capable of work ' 

relapse very often within the year. Dr. S. Fuchs-Wolfring 

(Paris) in a paper which is an amplification of one read 

in Rome at the Seventh International Congress for 

Tuberculosis, after showing how small are the results 

achieved in Germany and how great their cost, says : 

' It is only the reports of private sanatoria which are dis- 

' tinguished by an optimism which is in direct opposition 

' to facts. These optimistic reports are rendered possible 

' only by the employment of the elastic classifications 

' ' regained capability of work ' and ' working capability in 

' the sense of the law,' which are very deceptive and veil the 

' real facts as given in the official statistical reports. The 

' official reports acknowledge that the ' regained capability 

' to work ' so far only exists on paper. This method of 

' classification is a cruelty to patients and is misleading 

' from a national economic point of view." x 

It is true that there has been a considerable decline in 
tuberculosis in Germany, but there have also been sub- 
stantial declines in other countries where no special efforts 
had been made. When the Insurance Act was introduced, 
the death-rate in Germany from consumption, after many 
years of sanatorium benefit, was almost 50 per cent higher 
than it was in England and Wales. 

Mr. Lloyd George spoke of sanatorium benefit as an 
' experiment,' but it would probably be impossible to 
alter the scheme now that we have established sanatoria, 
appointed tuberculosis officers all over the country, and 
made arrangements with the doctors. We must keep our 
sanatoria as homes for care and treatment ; but we must dis- 
miss the extravagant ideas of cure which were promised. As 
far as the prevention of tuberculosis and the ' stamping out ' 
of this scourge is concerned, we are exactly where we were 
in 1911, with the exception that a number of false views 
have been propagated, and a great deal of money spent for 
very little return. This however is part of the price we 

1 Medical World, May 14, 1914. 


must continue to pay so long as we are content to be 
guided in the profound and difficult problems of Public 
Health by those who have no special knowledge of the 

The complex system of administration set up for 
sanatorium benefit will be more conveniently examined in 
Chapter X. in connection with Public Health administra- 
tion generally. 

Maternity Benefit 

This benefit has already been examined. It has not 
had any demonstrable effect in reducing maternal or 
infantile mortality, but has undoubtedly enabled many 
mothers to make better preparation for their confinement. 

Sickness Benefit 

Sickness benefit is a payment of 10s. a week to men 
and 7s. 6d. to women while ' rendered incapable of work 
by some specific disease or by bodily or mental disable- 
ment.' We have to consider: (1) the conditions which 
entitle to benefit, and (2), the influence of the benefit in 
the ' prevention and cure of sickness.' 

The difficulties which occur in connection with sickness 
benefit have given rise to much dissatisfaction. Insured 
persons complain that they do not always receive the 
payments to which they are entitled ; officials of Approved 
Societies state that malingering is encouraged and that 
the doctors' certificates are not reliable ; the doctors com- 
plain that they are called upon to give unnecessary certifi- 
cates, that their certificates are questioned and sometimes 
rejected by lay officials. Approved Societies agitate for 
more control over the doctors ; while the doctors chafe 
under the restrictions to which they are already subjected. 

The root cause of these difficulties is the fact that the 
right to sickness benefit is based upon an unsound principle. 
Benefit during sickness is only payable, according to the 
Act, when a person is ' rendered incapable of work.' In 
practice it is impossible in a very large number of cases to 
observe this condition. A person may still be capable of 


work — it depends a good deal upon the nature of the 
work — even if suffering from relatively severe illness. He 
may be able to work during the early stages of acute 
illnesses, or while suffering from chronic affections such as 
tuberculosis, heart-disease, aneurism, etc. Apart from 
severe affections, it is certain that if the Act were inter- 
preted literally, many thousands of payments in respect 
of anaemia, dyspepsia, and other conditions could not be 
justified. What therefore actually happens is that unless 
the doctor is dealing with a case of obviously incapacitat- 
ing illness, he pays little attention to the strict requirements 
of the Act. Established in his mind he has a kind of 
standard inherited from the old Friendly Society days, 
and if he thinks that a patient's condition is such that he 
ought not to work even if he could, or that a period of rest 
at home will appreciably facilitate his recovery, he gives 
a certificate for sickness benefit. 1 Thus the doctor and the 
Approved Society official tend to look at the case from very 
different points of view. The doctor regards chiefly the 
interests of his patient and the importance of getting him 
well ; the Approved Society official has his eye upon the 
funds of the Society, and tends to object to any payments 
for conditions which do not clearly satisfy him that the 
patient is incapable of work. With serious illness diffi- 
culty does not often arise, but, as we have seen, a con- 
siderable proportion of the working classes in large towns 
are in a chronic state of ill health in consequence of over- 
work or bad environment, without suffering from any 
clearly definable disease. A person comes to the doctor 
in such a condition that if he or she belonged to the 
wealthier classes, abstention from work would certainly be 
advised. But it is not possible for the doctor to do more 
than certify that the patient is suffering from ' debility,' 
or fix upon some prominent symptom such as ' anaemia,' 

1 Many utterances of panel practitioners might be quoted in support of this 
view. Dr. Round, the Chairman of the Deptford Panel Doctors' Committee, says, 
for example : " An old married woman has been under my care and on the funds 
for some months. She surfers from rheumatic arthritis, and earns her living in 
the winter as a wood-chopper, and during the summer she washes jam jars. Since 
when has a woman with rheumatic arthritis been fit to wash jam jars or chop wood, 
I wonder ? Members like this one deplete the funds no doubt, but the Act was 
instituted for the benefit of such people, and I, for one, am not going to ' bully them ' 
to go back to work." — Medical World, December 18, 1913. 


1 nervous exhaustion,' or ' dyspepsia,' and put that in the 
certificate. Then comes the Approved Society official, 
who complains that these are not serious conditions, that 
they do not incapacitate for work, and that the doctor is 
not making a careful diagnosis or giving his certificates 
with justification. 

This confusion results from a change having been made 
from one system to another without suitable adjustments 
having been introduced. The words ' incapable of work ' 
really come from the regulations of the old Friendly 
Societies, and though not interpreted literally even then, 
difficulty rarely arose, since the doctors knew what the 
Friendly Societies meant and required. Moreover, the 
relations between the Friendly Societies and the doctors 
who were appointed and paid by the Societies, were so 
close that difficulties when they arose were easily adjusted, 
and the doctors themselves were interested in the smooth 
and economic working of the Societies. The transference 
of the administration of medical benefit to Insurance 
Committees altered the whole relation of the doctors to 
the Societies ; but no thought seems to have been given to 
the question whether a form of words which had proved 
suitable for one system would be equally satisfactory when 
applied to a totally different system. 

The fact that there is not a constant relation between 
sickness and capacity for work probably explains the 
apparently excessive amount of malingering among insured 
persons. Some Insurance Committees have appointed 
medical referees to examine persons in receipt of sickness 
benefit, and these referees have invariably found that a 
considerable proportion of the persons examined were not 
legally entitled to the benefit. In one large Society, in 
six months, 12,375 members in possession of certificates of 
incapacity were requested to attend for examination by the 
Society's permanent medical referees, as a result of which 
1375 declared off the funds voluntarily ; 1795 failed to 
attend for examination ; and 3186 of the 9208 examined 
were declared ' capable of work ' by the referees. It 
would be an error to suppose that all those found capable 
of work were deliberate malingerers. Probably the doctors 


had considered that the conditions exhibited by the great 
majority of these persons were such that they ought not 
to be at work ; while the referee, taking the strictly legal 
view of the position, found himself unable to uphold the 
doctors' certificates. These considerations also explain 
why claims for sickness benefit tend to vary with the rate 
of wages and the general demand for labour. During 1915, 
when unemployment was reduced to a minimum, sickness 
claims fell off to a remarkable extent. It might be said 
that this was due to reduction of sickness in consequence 
of better food-supply, but probably the main reason is that 
when wages are good and work is abundant, ailing persons 
often pull themselves together and go to work, although 
they are in a condition in which many doctors would give 
them a certificate of incapacity ; just as the business man 
will sometimes disregard the advice of his doctor to lie up, 
and will insist on going to his office, perhaps to his serious 
detriment. When trade declines there is less inducement 
for persons to remain off the sick list, and in poorly paid 
occupations — for instance, some forms of women's labour — 
the amount received from benefit may actually exceed the 
amount which could be earned in wages. This is the more 
likely to occur among the large body of persons who are 
insured for sickness in private societies and organisations 
besides under the National Insurance Act. Thus, though 
the condition of the person may be the same at both 
periods, at one time there is an inducement for him to go 
to work, and at the other the inducement may be in the 
opposite direction. 

Probably no satisfactory scheme of sickness benefit 
will be established until the distinction between restora- 
tion to health and restoration to working capacity has 
been clearly recognised, and when recognised, its observance 
insisted upon. If sickness benefit is to be regarded strictly 
as a provision for preventing destitution until the recipient 
is just able to struggle back to work, then a clear intima- 
tion of this rendering should be given to the doctors. If, 
on the other hand, restoration to full health is the first 
concern, then the benefit should be supplemented without 
delay by public provision for higher medical treatment, 


institutional treatment, nursing, convalescent homes, and 
all other needs of an invalid which the Insurance Act does 
not provide and sickness benefit is insufficient to buy ; 
and the patient should be entitled to his benefit as long as 
he can derive advantage from any of these forms of treat- 
ment which would be interfered with by his return to 
work. In the long run, provision of these services would 
be the soundest national economy. At the present time 
sickness benefit, like maternity benefit, is undoubtedly a 
boon among the working classes during periods of illness, 
since it may enable the rent to be paid, may provide or 
help to provide food for the family, and may even save a 
family on the margin from having to go to the workhouse. 
But it has little effect in curing or preventing sickness, for 
it will not enable a patient to obtain what he needs, it will 
not send him to the country or seaside, and indeed it will 
usually not even maintain his normal income in health ; 
while a family which is just managing to keep itself afloat 
with the aid of the 10s. a week is not likely to be living 
under conditions which prevent sickness. 

Disablement Benefit 

Disablement benefit, a payment of 5s. a week while 
incapable of work after the expiration of sickness benefit, 
is admittedly a form of relief, and, as such, is a useful 
measure which does not demand criticism ; though it may 
be questioned whether it would not have been better to 
have made this provision by establishing invalidity pensions 
rather than by collecting the funds through the compli- 
cated machinery of the Insurance Act. 

The Insurance Act and Insanitary Conditions 

It is now necessary to examine the provisions of the 
Insurance Act which were specifically directed towards 
preventing disease by improving environment and attack- 
ing causes of sickness. The most ambitious of these is 
contained in Section 63 of the Act, which gives power to 
the Insurance Commissioners, or any Approved Society 
or Insurance Committee, to allege that the sickness among 


insured persons for the administration of whose sickness or 
disablement benefit they are responsible is excessive, and 
that such excess " is due to the conditions or nature of 
" employment of such persons, or to bad housing or in- 
" sanitary conditions in any locality, or to an insufficient or 
" contaminated water-supply, or to the neglect on the part 
" of any person or authority to observe or enforce the pro- 
" visions of any Act relating to the health of workers in 
" factories, workshops, mines, quarries, or other industries, 
" or relating to Public Health, or the housing of the working 
" classes or any regulations made under any such Act or to 
" observe or enforce any Public Health precautions." The 
Commissioners, Society, or Committee may then send to 
the person or authority alleged to be in default a claim for 
the payment of the extra expenditure alleged to have been 
incurred through any of the preceding causes, and if they 
fail to arrive at any agreement with the person or authority, 
they may apply to the Secretary of State or the Local 
Government Board for an inquiry to be held. 

If, upon such inquiry being held, it is proved that the 
amount of such sickness has 

"(i.) during a period of not less than three years 

before the date of the inquiry ; or 
" (ii.) if there has been an outbreak of any epidemic, 
endemic or infectious disease, during any less 
period " ; 

been in excess of the average expectation of sickness by 
more than 10 per cent, and that such excess was in whole 
or in part due to any of the causes enumerated, then the 
extra expenditure incurred must be made good by the 
employer or local authority or owner, lessee or occupier 
of premises, or water company, found to have been 

For the purpose of this Section the average expectation 
of sickness is to be calculated in accordance with the 
tables prepared by the Insurance Commissioners for the 
purposes of valuations, but neglecting excessive sickness 
due to disease or injury in respect of which damages or 
compensation are payable under the Employers' Liability 


Act, or the Workmen's Compensation Act, or at Common 

At first sight these provisions may appear very drastic 
and far-reaching, but closer examination will show that 
they are simply bristling with difficulties. At the moment 
of writing, five years after the passing of the Insurance 
Act, no steps have been taken to put them into force, and 
it is exceedingly doubtful whether they ever could be put 
into force. The great difficulty arises from the fact that 
the sickness rates necessary to prove the allegation, must 
be compiled in regard to a definite body of persons who 
are subject to the influence or neglect complained of, such 
as the employees of a particular factory, the occupants of 
an area of bad housing, or the persons supplied with 
drinking - water by a particular company or authority ; 
whereas all our statistical information relating to sickness 
is in terms of membership of Approved Societies, a large 
number of which may be represented among the body of 
persons in respect of which action is taken. There is no 
relation between the sickness rates we possess or are 
accumulating, and those required for the purposes of this 
Section. Some examples may demonstrate the difficulties 

Let us take what is probably the simplest case, that of 
a factory where, say, 500 insured persons are employed ; 
let us suppose that the allegation is made by an Approved 
Society which considers that the provisions of some Public 
Health Act are not being enforced in the factory; and 
further, for the sake of simplicity, let us suppose that all 
the 500 employees belong to one Approved Society. In 
order that the allegation may be proved, the Society will 
have to keep for three years a special record of the exact 
numbers of its members in the factory, and their sickness 
and age and sex constitution. But this number will vary 
not only from year to year, but from month to month and 
week to week with normal and abnormal periods of trade 
activity or depression. Persons will drop out of insurance 
on marriage, or for other reasons, or will fall into arrears ; 
others will change their Society or go into other employ- 
ment, or be lost sight of. Experience has shown that 


insured persons are not prompt in keeping their Societies 
informed of changes of address, and whenever a general 
notice is sent out by a Society or an Insurance Committee 
a considerable proportion of the notices are returned 
through the ' dead letter ' office. When the number has 
been arrived at, and the aggregate sickness determined 
after deducting sickness due to disease or injury in respect 
of which damages, etc., are payable, it will still be neces- 
sary to know the exact ages and sex constitution of the 
employees in order to apply corrections for the natural 
excess of sickness among elderly persons and women, for 
the purpose of rendering the sickness rate comparable with 
the average expectation of sickness. It is obvious that a 
Society would find it exceedingly difficult to maintain the 
close touch necessary to obtain a result within 10 per cent 
of accuracy with a continually fluctuating group of its 
members ; and when we add the fact that ordinarily the 
500 employees will be distributed among a number of 
Societies the difficulty of even the first step becomes almost 

But let us suppose that such a rate has been deter- 
mined, and that it is in excess of the average expectation 
of sickness by more than 10 per cent. It is now necessary 
to show that the excess was due, in whole or in part, to 
neglect of the employer to enforce statutory provisions 
relating to health in the factory. It would, however, be 
almost impossible to separate the effect of any particular 
adverse factor in the factory from other hostile influences 
acting independently from the factory. In an industrial 
town a large proportion of the employees may be badly 
housed, overcrowded, inadequately treated when ill, and 
living under defective conditions of sanitation. Inebriety 
may be more than the average ; and it may be impossible to 
disprove the assertion that the excess of sickness was due 
to climatic conditions, an exceptionally hot summer or 
severe winter. If in all other respects the operatives were 
living under healthy conditions, the excess of sickness 
among them might conceivably be attributed to conditions 
in the factory ; or if these conditions were outrageously 
bad, they might be held to outweigh other influences. 


But in these days of factory inspection it is hardly con- 
ceivable that such a state of affairs could continue for 
three years. Breaches of the Factory Acts are usually 
relatively small, and it is impossible to imagine that the 
instances of neglect in the degree usually met with, such 
as some insufficiency of cubic space, or inadequacy of 
working arrangements or sanitary conveniences, could ever 
produce the immense effect necessary to outweigh all the 
adverse influences usually associated with industrialism. 

Nor do these arguments by any means exhaust the 
possible defences and replies open to an employer. It 
might happen, for example, that a few cases in excess of 
the average of a disease accompanied by long illness, such 
as cancer, for which the employer could not be held re- 
sponsible, might appreciably raise the average sickness 
among the relatively small number of employees. If, to 
take another illustration, it is hoped to avoid this difficulty 
by applying the process to a much larger number of 
persons, say some thousands of men employed in a mine, 
then the difficulties previously described of keeping in 
touch with this mine population for three years, deter- 
mining their sickness rates, etc., are proportionately in- 

Taking all these facts into consideration, it is safe to 
say that no Society with its members scattered all over the 
country is going to undertake the labour of collecting for 
three years the evidence, and compiling the rates neces- 
sary for a highly problematical result, at the best only 
repaying them a proportion of the expenditure on sickness 
and disablement benefit, which would probably cost less 
to pay without question. The Section also provides that 
where the excess of sickness is found to be due to an insuffi- 
cient or contaminated water-supply, the local authority, 
company, or person by whom the water is supplied must 
pay the extra cost, unless it can be shown that the insuffi- 
ciency or contamination arose from circumstances over 
which they had no control. Let us imagine an allegation 
against a water company supplying part of a large town. 
In this instance the Society taking action must ascertain 
the exact area of streets and houses supplied by the com- 


pany or authority, and the numbers, sickness, and details 
as to sex and age of all its members who live in that area 
— a practically impossible task. Having found that their 
sickness rate is 10 per cent in excess of the average, they 
must then prove that this sickness was due to the bad 
water-supply, and they must be prepared to refute the 
defence that the badness was due to circumstances over 
which the company had no control. Both these involve 
highly complex scientific questions which would entail 
costly expenditure upon expert witnesses and counsel. 

The Section however does not limit the right to make 
allegations to an Approved Society, but empowers the 
Insurance Commissioners or an Insurance Committee to 
take action, the latter being only able to act on behalf of 
deposit contributors, while the Insurance Commissioners 
can act on behalf of any insured persons. Let us see what 
this would involve if the Insurance Commissioners con- 
templated taking action against an authority or employer 
in regard to all the insured persons engaged in a particular 
employment, or deriving their water-supply from a common 
source, or living in an area of bad housing. Since there 
are no general rates of sickness whatever in terms of 
geographical or administrative areas, the Insurance Com- 
missioners in order to establish the sickness rates on which 
to proceed with their allegation would have to obtain from 
every Approved Society which has members engaged in the 
particular occupation, or supplied by the water-supply, or 
living in the area of bad housing (which apparently the 
Commissioners can define as they please), a return showing 
for three years the number of these members, and the 
sickness among them, and their ages and sexes ; and it 
must obtain from the Insurance Committee or Committees 
similar details in respect of deposit contributors. If the 
number of persons selected for the process is small, then the 
averages will not be reliable ; if the number is large, then 
the Societies involved may amount to many hundreds. 
The labour in compiling the sickness rates would be gigan- 
tic, and by the time it was finished probably the whole 
thing would be hopelessly out of date. 

There is yet another difficulty. When the allegation 


is made against a factory owner, a water company, or a 
local authority, at least the person held to be responsible 
is clearly defined. But when action is taken in regard to 
an area of bad housing, the property impugned may be in 
the hands of a number of owners, lessees, and occupiers, 
and the responsibility may be partially shared by the 
Local Authority. This opens up a prospect of endless 
dispute and litigation, for even if it were proved that the 
bad housing of the district were responsible generally for 
the excess of sickness, it would be almost impossible to 
apportion responsibility among individual owners, occu- 
piers, and local authorities. 

Apart from the hopeless complexity of the machinery 
of this Section there is another condition which practically 
nullifies its value for Public Health purposes. Excess of 
sickness is to be determined by comparison with the 
' average expectation of sickness,' which is to be calcu- 
lated in accordance with tables prepared by the Insurance 
Commissioners for the purpose of valuations. Presum- 
ably an average expectation for each sex, and for each 
year of age, will be determined for each of the four king- 
doms. But the object of the Section is to detect excess- 
ive sickness due to local causes, and for this purpose 
the comparison should be between the group subjected to 
this special cause of sickness and other persons living 
under approximately the same conditions except as regards 
the special cause. What is really required is an average 
local sickness rate for every district. The comparison 
with the rate for the whole country takes no note of broad 
differences due to climatic conditions or general character 
of the environment or occupation. In the agricultural 
South of England the standard of comparison would be too 
high ; in the industrial districts of the North it would be 
inequitably low. In a rural town or district of Sussex 
it might well happen that a local cause was appreciably 
increasing the sickness rate among a group subjected to it, 
above the sickness rate of the district, yet when the com- 
parison is made between the sickness of the group and the 
average expectation of the whole country, no excess may 
be apparent, simply because the general conditions of the 


district are so healthy. On the other hand, in a crowded 
mining or industrial town, the general sickness rate may 
be constantly 10 per cent or more above the average 
expectation of the whole country, owing to the aggregate 
evils of industrialism, and it would be impossible to prove 
that an individual manufacturer was responsible for the 
excess in his particular mill. As the writer interprets the 
Act, comparison cannot be made with local sickness rates 
for the purposes of this Section ; but even if it could be, 
the extreme difficulty of determining those rates remains. 

The above paragraphs have analysed the leading 
principles of Section 63. In detail the whole Section is 
very vaguely drafted, and contains numerous words and 
phrases, such as ' any public precautions,' ' any extra 
expenditure,' ' period,' ' conditions or nature of work,' ' in 
default,' ' insufficient,' ' contaminated,' ' payable,' etc. etc., 
which are not further defined, and would give rise to inter- 
minable legal argument. These points are investigated in 
National Insurance, by Messrs. Carr, Garnett, and Taylor. 

Section 63 of the National Insurance Act was presum- 
ably drafted in a Government Department, but it seems 
impossible to believe that it was ever submitted for criticism 
to any one with a knowledge of statistical requirements or 
Public Health administration. It was debated at length 
in Parliament, but there also no one pointed out its inherent 
absurdity. This fantastic scheme seems to regard sickness 
as something which can be measured in a pint-pot, and it 
is based upon a mechanical conception of society which 
assumes that human beings can be sorted, grouped, and 
ticketed in a way that a shepherd would find difficult with 
his flock. Unlike some Sections of the Act it has not led 
to a great waste of money ; it has been, and will be, merely 
a dead-letter, but none the less it illustrates the futility 
of legislating on Public Health without consulting expert 

The Insurance Act and the Advancement of 
Public Health Knowledge 

One of the numerous advantages promised from the 
Insurance Act was increase of knowledge relating to the 


causes of disease. As far as purely scientific investigations 
are concerned, there is good reason to hope that this 
promise will be fulfilled. A Research Committee has been 
set up, and provided with funds amounting to approxi- 
mately £60,000 per annum. Investigators working under 
the Committee have already published papers of value, 
and during the War the Committee has been conducting 
research in military hygiene. Although one of the least 
costly, the establishment of this Committee may eventu- 
ally prove to be one of the most valuable provisions of the 
Act, though it may be pointed out that the Committee is 
no part of the general insurance scheme, and could have 
been appointed independently at any time of the long 
period during which the need tor research has been becom- 
ing steadily more urgent and more apparent. 

But the Research Committee cannot build without 
bricks, and it is not constituted to collect for itself the 
immense mass of information relating to the causes and 
distribution of sickness which is urgently required for 
Public Health purposes. It is moreover quite clear that 
the promoters of the Insurance Act intended that its 
machinery should be used for the collection of data and 
advancement of knowledge altogether independently of 
the scientific investigations undertaken by the Research 
Committee. Speaking in 1913, Mr. Lloyd George said : — 

" To heal disease is good work ; to hinder it is best. 
That will be the work of the Act. An official will go round 
like an angel of light and ask, ' What is the matter ? ' ' What 
can we do for you ? ' Their wants will be recorded. We 
shall know what is happening, and, believe me, knowledge 
is hope. That is what we are going to get from the Act. 
And we will get it. It was worth you and myself taking 
off our coats and facing opposition, misrepresentation, 
calumny, and I thank you. We shall know something 
about the causes of disease, bad housing, overcrowding, 
bad industrial conditions, underfeeding, drink — we shall 
know it all, all the evils that are sapping the vitality of 
the race, depressing the energies of the people and destroy- 
ing their lives. We shall know year by year more and 
more, and as sufficient knowledge accumulates in the 



minds of all classes in this country of what is happening, 
they will put an end to it whatever it costs." 1 

We do not know what official Mr. Lloyd George had in 
his mind as this celestial visitor, and it is not easy to 
recognise an ' angel of light ' in either an insurance in- 
spector or Approved Society agent, but it is certain that 
no investigations of the kind indicated have been or are 
being made. There are however two possible directions 
in which the machinery of the Act might have been 
employed in collecting information, viz. reports from 
Insurance Committees, and records kept by the doctors ; 
but not much can be expected from the first, and in regard 
to the second the Insurance Commissioners have estab- 
lished a system which completely defeats its object. 

Section 60 of the Act places on an Insurance Committee 
the following obligation : — 

It shall make such reports as to the health of insured persons 
within the county or county borough as the Insurance Commis- 
sioners after consultation with the Local Government Board may 
prescribe, and shall furnish to them such statistical and other 
returns as they may require, and may make to them such other 
reports on the health of such persons, and the conditions affecting 
the same, and may make such suggestions with regard thereto as it 
may think fit. 

The Insurance Commissioners are then required to 
send copies of these reports and suggestions to the 
' councils of the counties, boroughs, and urban and rural 
districts which appear to be affected.' The reports and 
returns must ' enable an analysis and classification to be 
made of the persons who are deposit contributors.' 

Incidentally we may note the extreme degree of 
centralisation and complexity of administration which this 
system involves : Insurance Committees not communicat- 
ing directly to the local authorities in their own district, 
but reporting to the Insurance Commissioners, who then 
send the reports back to the local authorities. Up to the 
present the Insurance Commissioners have not prescribed 
any reports, and Insurance Committees have done little 

1 The Times, January 18, 1913. 


on their own initiative, probably because their time is 
so fully occupied with administrative details. It should 
be observed however that Insurance Committees are to 
make statistical returns, which alone possess scientific 
value, and these returns must at least separate deposit 
contributors. But at once the Committee encounters the 
obstacle already described, viz. that while it exercises 
authority over a defined geographical area, the records of 
sickness among insured persons in that area are scattered 
through innumerable offices of Approved Societies all over 
the country. An Insurance Committee does not even 
know within a considerable margin of error the number 
of persons for whom it administers medical benefit. Thus 
any reports it may make will either refer to small groups 
about whom it can readily obtain information, such as the 
inmates of a sanatorium ; or will be of a perfectly general 
character, in which case they will be covering, for insured 
persons, ground already covered much more fully for the 
whole community of the district by the Medical Officer of 

The greatest opportunity for the collecting of scientific 
information lay in the medical records kept by the doctors. 
One of the conditions attached to the extra Parliamentary 
grant for medical benefit was that the doctors should keep 
these records, solely for the advancement of medical know- 
ledge. They are quite distinct from the sickness certifi- 
cates, and are not required for any other purposes, financial 
or administrative. The Commissioners seem however to 
have failed entirely to understand the scientific object of 
these records, and instead of seizing an excellent oppor- 
tunity for adding to knowledge, they have devised a 
system which, while giving the doctors considerable labour, 
has not and will not yield results of the smallest scientific 
value. They have required the doctors to keep a record 
of every case which comes before them, and since the 
great bulk of insurance patients are suffering from rela- 
tively trivial affections, which often can only be defined 
by reference to some prominent symptom, the result is a 
mass of ill-defined entries without any information as to 
the cause, treatment, or course of the case, which is 


utterly useless for scientific purposes. 1 In an actual 
record of 100 consecutive cases in an urban district, 
'bronchitis' occurs 17 times, 'tonsillitis' 11 times, 
' influenza ' 7, ' muscular rheumatism ' 5, ' nervous de- 
bility ' 5, and ' general debility ' 4 times, while other 
entries are ' anaemia,' ' constipation,' ' dyspepsia,' ' cephal- 
algia,' ' inflamed glands,' ' ulcer of leg,' ' contused eye,' 
' sprained ankle,' and ' septic hand.' 

It does not require scientific training to realise that no 
use could be made of a list of entries of this kind. It 
might however be said that we could at least pick out from 
the lists entries of graver diseases, such as cancer or tuber- 
culosis, and use these as a basis for scientific investigation. 
But herein, apart from the fact that no detailed informa- 
tion is given, another difficulty presents itself, viz. that 
the Commissioners have not prescribed any uniform 
system of terminology to be used by the doctors. In the 
Registrar-General's classification of the causes of death 
an International List of diseases is employed, and medical 
men are given instructions to avoid in death- certificates 
various terms which are not clearly defined ; but nothing 
of the sort has been prescribed in the insurance records. 
With sickness, even more than mortality, it may be 
possible to describe a given condition under one of several 
headings, hence in attempting to collate the panel doctor's 
records, serious error would arise owing to absence of 
uniformity in terminology. The system is not only 
wasteful and irritating, but is discouraging to those doctors 
who are really interested in the scientific side of their 
profession. 2 

Finally it may be noted that if, as appears to be the 

1 These records are now kept on cards, but at first the Commissioners issued 
an unwieldy and unworkable ' day-book,' which, after being distributed all over 
the country, was withdrawn in a few weeks. 

2 This effect is well expressed in the following extract from a letter written 
by a panel practitioner : " I hope I am sufficiently public -spirited willingly to do 
any reasonable work calculated to be of any real public or economic value, but the 
keeping of this enormous mass of utterly useless information, which one knows 
will never be used and never could be used because of its irrelevance, fills one with 
a sense of profound depression and wasted energy. The time and effort wasted 
over recording the occupation, age, sex, number, and society of every man and 
woman who has a headache or a stomach-ache or a cut finger or a sleepy feeling in 
the morning might be so much better spent either in attending to the patients' 
ailments or in keeping real records of genuine value." 


case, some 50 per cent of insured persons consult the 
doctor in the course of the year, the total number of record 
cards sent to the Commissioners at the end of the year will 
amount to six or seven millions. When it is remembered 
that the Registrar-General and his staff are only called 
upon to deal with less than half- a- million death-certificates 
in the course of the year, the immense labour involved 
and the large staff necessary to collate the panel records 
become apparent. Even if it be desired to deal only with 
a single disease, every card must be examined to obtain a 
record applicable to the whole country. Probably long 
before the investigation was completed, the utter useless- 
ness of the whole proceeding would have been realised 
and the cards consigned to the waste-paper basket : yet 
the Commissioners have inflicted substantial fines on 
doctors for not sending in these worthless records. It is 
impossible to believe that the Insurance Commissioners 
obtained advice from any one possessing knowledge of 
statistics or scientific medicine before they devised this 
extraordinarily inept scheme. 

We may note the opportunities the Commissioners have 
lost. There are several conditions in regard to which 
information is urgently needed, and the Commissioners 
could have selected some of these conditions, and required 
the doctors to furnish full details of them, their cause, 
treatment, etc. (except names of patients), to the ex- 
clusion of all else. Syphilis, for example, is a disease of 
which our statistical knowledge is exceedingly scanty and 
unreliable. The importance of collecting information 
regarding the prevalence of this disease was emphasised 
by the Committee on Physical Deterioration in 1904, and 
subsequently in various reports of the Local Government 
Board and at the International Congress of Medicine in 
1913. We have really no accurate information of the 
prevalence of this disease, and if the Commissioners had 
required panel doctors to record every case of syphilis, with 
details of its origin (congenital, acquired, marital infec- 
tion, etc.), the treatment adopted, and the course of the 
case, much useful information regarding active syphilis 
among insured persons would have been available for the 


purposes of the recent Royal Commission on Venereal 
Diseases. Another subject on which knowledge is re- 
quired is the extent of abortion, natural or criminal ; we 
are told that pre-natal loss of life is very heavy, and that 
artificial methods of causing abortion are widespread and 
increasing, but statements of the number of cases are 
based upon little more than guess-work. Chronic lead- 
poisoning might have been added to these two subjects. 
-The Departmental Committee on the Use of Lead in 
Painting of Buildings point out that there are no reliable 
statistics relating to lead-poisoning, except among persons 
who come under the Factory Acts ; and in their report, 
issued after the Insurance Act had been in operation for 
more than two years, they recommend that the machinery 
of the Act should be used for collecting this information. 
If a few conditions such as these had been selected for 
recording, it would probably have been possible to obtain 
the co-operation of the hospitals and thus increase the 
value of the records. The conditions could be changed 
from time to time, or different conditions examined in 
different localities ; and if the Commissioners did not 
possess among themselves sufficient knowledge of Public 
Health science to determine what conditions should be pre- 
scribed, they could presumably have obtained advice from 
the Local Government Board or the Registrar-General. 

If the Insurance Commissioners had focussed attention 
upon these three subjects, the total amount of labour 
demanded from the doctors in keeping records would have 
been far less than that required at present ; the doctors 
would have undertaken it willingly since they would have 
appreciated its scientific and Public Health importance ; 
and the knowledge gained would have been much greater 
than anything likely to result from the present cumber- 
some, inaccurate, and futile scheme. 

Many other questions which have arisen under the 
Insurance Act are not dealt with here since they do not 
touch its larger Public Health aspects. Such are the 
solvency or otherwise of the scheme ; the appalling com- 
plexity of administration ; the difficulties regarding married 


women ; the question of arrears, the regulations concern- 
ing which extend to sixty-five sections ; the confusion of 
the registers ; and the position of deposit contributors — 
questions which have already entailed numerous com- 
mittees and other forms of inquiry. In taking a broad 
view, the advantages of the Act must not be minimised. 
The weekly payments of sickness benefit have undoubtedly 
helped many poor persons through a period of distress ; 
maternity benefit has been a substantial boon to mothers ; 
and disablement benefit has constituted a small pension 
for incapacitated persons. But these benefits are all in 
the nature of Poor Relief under another name, and they 
do little to alter the conditions which bring about sickness. 
As far as improvement of the Public Health is concerned, 
the influence of the Act has probably been almost nil. 
The medical service is no better than that which preceded 
it, the main change being that a certain number of persons 
who formerly went to infirmaries and hospital out-patient 
departments now go to panel doctors ; sanatorium treat- 
ment has proved of little value among the working classes ; 
the provisions intended to deal with the evils of bad 
housing and insanitary conditions are unworkable ; and 
the schemes for collecting Public Health information are 
futile, though the Research Committee will probably add 
to our knowledge of scientific medicine. Nearly all classes 
grumble at the Act, and though the panel practitioners 
have benefited financially, the medical profession has been 
split into two camps between which much bitterness exists. 
The Act is unsound as a scheme of Insurance, since the 
flat rate of contribution assumes an equality of risk which 
does not exist ; the lower incidence of sickness in rural 
districts making it in effect a tax on rural industries and 
occupations, for the benefit of town- dwellers. 

The root cause of the failures in the directions indicated 
is from first to last the absence of expert knowledge among 
the framers and administrators of the measure, and their 
omission to obtain expert criticism of their proposals or 
their disregard of this criticism when given. The Act was 
based upon the shallowest knowledge of the results of a 
similar measure in another country, where more thorough 


investigation would have shown that the effects upon 
Public Health had been very small ; it was not subjected 
to adequate examination during its passage through Par- 
liament; and finally its administration in England was 
entrusted to a body of persons who did not include in their 
number any with special Public Health knowledge or 
experience. The War has made the importance of 
securing sound health among the people overwhelming. 
To achieve this result immense efforts are required in 
numerous directions. Continuation of the present system 
will inevitably lead to further great mistakes and pouring 
out of money in directions from which we shall get little 
or no return. If real improvement is sought, the essential 
first step is to place at the disposal of legislators and 
administrators, when dealing with Public Health, that 
assistance of science which is now so eagerly demanded in 
the spheres of commerce, industry, and education. 



Adulteration of food — Unsound food — Conditions under which food is pre- 
pared — Patent and proprietary foods — Patent and proprietary 
medicines — Unqualified practice. 

Adulteration of Food 

Adulteration of food is a serious evil in this country, 
but there is no means of measuring fully its injurious 
effects. Unsound food may cause acute illness and even 
death ; adulteration, however, is rarely so excessive as to 
produce these results, but manifests its harmfulness chiefly 
in dyspepsia, gastro-intestinal irritation, headache, etc., 
and, particularly among infants and children, in mal- 
nutrition owing to the food not possessing the nutritive 
value with which it is credited. 

It is not easy to give a picture of the extent to which 
adulteration is practised, since the detected instances only 
represent a fraction of those which occur ; and because 
Local Authorities, Medical Officers of Health, and In- 
spectors of Foods find themselves obliged to allow many 
forms of the evil to flourish unchecked, though perfectly 
well aware of what is going on, owing to the faulty 
machinery at their command for preventing these practices. 
Sometimes it is the laxity or obscurity of the law which is 
responsible, and at other times it is the impossibility of 
securing the conviction of an offender before a particular 
magistrate. The annual reports of the Local Government 
Board contain much interesting information relating to 
adulteration and contamination of food, and from these 
most of the following statements concerning our principal 
food-stuffs are taken. 



Milk. — The importance of a pure milk-supply needs 
no emphasis. Milk forms, or should form, one of the 
staple foods of all young children, while for infants it is 
the best substitute — if a substitute is necessary — for 
mother's milk. The ill-effects of cows' milk, sometimes 
seen in infants, are probably most often due to the fact 
that the milk has been adulterated, contaminated with 
dirt, or infected with micro-organisms. For infants whose 
mothers are unable to feed them naturally, a supply of 
pure cows' milk is of the greatest importance. 

During the year 1913, in England and Wales, 52,304 
samples of milk were analysed under the Sale of Food and 
Drugs Acts, and of these, 5533, or more than 10 per cent, 
were found to have been adulterated or were not up to 
the minimum standard fixed by the Regulations. The 
adulteration of milk by the addition of water is now giving 
way to a more ingenious process less liable to detection, 
which is termed ' toning.' This consists in adding to 
pure milk the separated milk remaining after the fat has 
been extracted for the manufacture of butter or cream, 
which would otherwise be a waste product or perhaps be 
used in country districts for feeding pigs. The increase 
of toning in London during recent years is reflected in the 
statistics relating to milk adulteration. Up to 1907 the 
rate of adulteration was always higher, and often a great 
deal higher, in London than in the provinces ; but since 
that date the position has been reversed, and the adultera- 
tion returns in the metropolis have declined by 35 per 
cent in recent years. The Local Government Board how- 
ever points out that control of the milk sent to London 
has passed more and more into the hands of middlemen 
and large companies, who are well aware of the quality of 
milk demanded by the Regulations, and are in a position 
to tone it down or standardise it by the addition of separ- 
ated milk before it is distributed to the retailers. Thus 
there is little scope for milkmen to dilute the milk further. 
Adulteration is the same, but it is effected by few persons 
instead of many, and thus the number of convictions 
declines. The Board says : " We understand that as a fact 
" toning or standardising milk is regularly practised in 


" certain quarters, and that this is done with skill and 
" precision, so that official limits are seldom passed. It is 
" most difficult under the present law to bring home any 
" offence to the scientific ' toner.' Whatever may be the 
" explanation of the difference in recent years between 
" London and the provinces, it is open to doubt whether 
" the decrease reported in the rate of London milk adultera- 
" tion is accompanied by any corresponding increase in the 
" quality of the milk- supply." 

In the provinces the percentage of milk adulteration 
in samples taken has risen from 9'5 during the period of 
years 1899-1903, to 113 during the period 1909-13. 

Facts such as these illustrate the extreme difficulty of 
circumventing the wiles of dishonest milk-vendors. In 
spite of all our Acts of Parliament, regulations, and inspec- 
tions, adulteration of milk is increasing in the provinces, 
and its apparent decline in London is accompanied by a 
supply of inferior quality. There seems nothing to prevent 
the practice of toning spreading all over England, so that 
ultimately, in towns at least, it may be impossible to get 
anything but the poorest quality of milk. 

Apart from the addition of separated milk or water, 
milk may be adulterated by adding to it boric acid, form- 
aldehyde, glycerine, sodium nitrite, and colouring matter. 

It is very interesting to trace the subsequent history of 
the 5533 samples of milk mentioned above as having been 
reported against during the year. In only 2418 instances 
were criminal proceedings taken by Local Authorities, and 
convictions were secured in 1767 cases, with penalties 
amounting in the aggregate to £4136. There were 256 
fines of £5 each and upwards, fifty-three being of £10 each, 
fifteen between £10 and £20, nine of £20 each, four of £25, 
four of £30, seven of £50, and two of £100. It will be seen 
therefore that even if an offence is detected, the chances are 
still nearly three to one against a conviction being secured. 
Moreover the bulk of the fines are so small that dishonest 
vendors find it profitable to continue their practices and 
pay any penalties they may incur. Reporting on a 
milk company formed to take over the ' business of a 
previous company ' which had been convicted more than 


twenty times, the Middlesex Health Committee states 
that the new company had to be prosecuted during the 
year and was fined £70. The report continues : " It is 
expected that this company will shortly be succeeded in 
its turn by another, which will then be able if necessary 
to come before the Courts with a clean record." In 
another instance a company which had been fined £50 
immediately dissolved in order to avoid payment of the 

Besides deliberate adulteration, milk is liable to be 
contaminated with dirt or infected with micro-organisms 
at various stages in its passage from the cow to the con- 
sumer. The milker may be dirty in his person or his 
habits, the pails and cans may be imperfectly cleaned, and 
the milk may be polluted in transit or while stored in in- 
sanitary premises or exposed for sale in shops. Something 
like 10 per cent of the samples of milk examined are found 
to contain the bacilli of tuberculosis, and it is recognised 
that this is a contributory cause of abdominal tuberculosis 
in children. 

The final result is that the milk supplied to a large 
proportion of children in the poorer quarters of towns is 
a weak, dirty, and dangerous fluid. The law is inadequate 
to prevent adulteration ; Local Authorities have in- 
sufficient control over cowsheds, dairies, and dairymen ; 
and the fines for adulteration inflicted by magistrates are 
disproportionately small. It is doubtful whether any 
remedy will be found for these evils, until some system of 
control over the milk-supply is established, analogous to 
that which governs the supply of water by Municipalities. 
Local Authorities could then own their cows and be held 
responsible for the cleanliness and transit of the milk from 
start to finish. 

Cream has an even worse record than milk. Under 
the Public Health (Milk and Cream) Eegulations, cream 
which is sold as ' cream ' and not as ' preserved cream ' 
must not contain any preservative ; but of 1026 samples 
described only as ' cream ' which were analysed in 1913, no 
less than 410 were found to contain a preservative which 
consisted of boric acid in all but four samples, in which 


it was a fluoride. Again it is interesting to note the sub- 
sequent history. The Regulations provide that before the 
Local Authority institutes legal proceedings, it shall afford 
the person implicated an opportunity of explaining the 
circumstances. This procedure was followed in 263 cases, 
and in 239 the Authority accepted the explanation, but 
administered a caution in most instances. In regard to 
143 cases, in which ' cream ' had been found to contain 
boric acid, no action was taken, chiefly because the 
samples had been purchased without the prescribed 
formalities. Legal proceedings were instituted in twenty- 
four instances. In five cases the magistrates dismissed 
the summonses, in twelve they were withdrawn, and in 
only seven cases were convictions obtained with fines 
ranging from Is. to £5. 

Butter. — The samples of butter examined during the 
year numbered 21,932, and of these, 1131, or 5'2 per cent, 
were condemned. In the majority of cases margarine had 
been substituted for butter ; in other instances there was 
an excess of water, or a preservative consisting of boric 
acid, sodium fluoride, or sugar had been added. Besides 
the samples condemned, there were 6866 other samples 
which, though passed as genuine by the analysts, contained 
boric acid. In all, over 33 per cent of butter samples con- 
tained preservatives. Sometimes when proceedings are 
taken before a magistrate for adding boric acid to food, 
evidence is brought to show that the small amount present 
would not be harmful Medical opinion by no means 
accepts this as established ; but even if it were so, it must 
not be forgotten that boric acid is added to so many 
varieties of food that the total amount consumed may be 

Margarine appears to be less subject to adulteration 
than butter. An ingenious method of substitution is to 
fill the centre of a roll of butter with margarine, the sample 
cut off from the end by the inspector being then found to 
be genuine. Incidentally it may be noted that up to 
1913 the Board of Agriculture had approved of 1831 names 
for margarine and 44 for mixtures of butter with milk. 

Other articles of food which are frequently adulterated 


are flour, coffee, cocoa, sugar, confectionery, jam, rice, 
sago, potted meat and fish, and sausages. Of a total of 
108,157 samples analysed in 1913, the number found to 
have been adulterated was 8860, or 8*2 per cent. The cunning 
of dishonest traders is illustrated by their practice, now well 
known to Medical Officers of Health, of selling only genuine 
articles to a stranger lest he may be a food inspector. 
This is continued until the purchaser is regarded as an 
ordinary regular customer, when an adulterated article 
will be supplied again and again. The reports of the 
Local Government Board every year describe numerous 
instances of fraudulent practices, but they never mention 
the names of persons convicted. This has an appearance 
of unnecessary concern for the protection of dishonest 
traders, and the establishment of a ' black list ' might be 
a deterrent step. Medical Officers of Health have already 
adopted this course in certain localities. 

The Sale of Food and Drugs Act, under which proceed- 
ings for adulteration are usually taken, prohibits the sale 
of any article of food to the prejudice of the purchaser 
which is not of the ' nature, substance, and quality de- 
manded.' These words have formed a fruitful source of 
legal argument, and their vagueness has enabled many an 
offender to escape the consequences of his dishonesty. 
Except for milk, cream, and butter no standards in regard 
to the nature or quality of foods are laid down by any 
Acts of Parliament or regulations ; and no Authority has 
power to prescribe standards or to state what a food should 
or should not contain. When criminal proceedings are 
taken, expert witnesses may be called by each side, scientific 
evidence is given, and the Bench of Justices or Stipendiary 
Magistrate, without any power to summon an assessor and 
usually without expert knowledge themselves, must come 
to a decision on matters involving an intimate knowledge 
of chemistry, physiology, and hygiene. The result is that 
practice varies from place to place, one Bench convicting 
where another would dismiss the charge, and decisions are 
given, some of which are not in the interests of Public 
Health, though we must assume them to be sound law. 
It has been held, for instance, that a mixture of cocoa 


containing 18 per cent of the husk or shell of the cocoa nib 
is of the ' nature, substance, and quality ' demanded 
when ' cocoa ' is asked for, and may be sold under that 

The uncertainty of magisterial decisions reacts upon 
the food inspectors, who cease to take samples when they 
know it will be almost impossible to obtain a conviction 
for an offence. Mr. R. A. Robinson, the inspector under 
the Food and Drugs Acts for Middlesex, writes : " There 
are at the present time practically only two articles of 
food (milk and butter) which are to any serious extent 
adulterated in such a way as to make it reasonably possible 
to institute proceedings successfully. ... I do not feel, 
save in very exceptional cases, that I can usefully advise 
proceedings to be instituted in respect of any of the follow- 
ing among a host of other articles — cream, vinegar, jams, 
golden syrup, treacle, aerated waters, rice, preserved 
vegetables, tinned fruits, chocolate, lime juice, sausages, 
potted meats, wines, and various drugs." * 

Unsound Food 

Apart from adulteration, food may be unfit for human 
consumption from the presence of disease in the animal, 
or from decomposition, the danger attending the latter 
being far greater with animal than vegetable food. 
Diseased or unsound meat may be seized by a Medical 
Officer of Health or Sanitary Inspector when exposed for 
sale or deposited in any place for the purpose of sale, and 
the meat is then submitted to a magistrate, who has power 
to order its destruction. In many districts where the 
inspectors are vigilant, their powers seem to be sufficient 
to prevent the sale of unsound meat, but in this matter 
also, different standards of meat inspection exist in con- 
tiguous districts and give rise to many anomalies. The 
Local Government Board has repeatedly called attention 
to the need of a uniform system throughout the country. 
One effect of the differences in standard is that diseased 
animals or unsound meat are transferred from districts 

1 Transactions of Medico-Legal Society, vol. vii. 


where inspection is severe to districts where it is lax, and 
sold therein. The following example of this practice is 
quoted from a medical officer's annual report in the Local 
Government Board Report for 1913-14 : — 

I received information that a beast which was very emaciated 
had been slaughtered on unlicensed premises early in the morning 
and was being conveyed into the town. As my information was 
very imperfect, I had some difficulty in tracing the matter. After 
instituting inquiries I visited some stables but found them locked. 
The occupier, who saw me enter the yard, had disappeared when I 
came out to require admission to the stables. I accordingly set a 
trap for him, and as a result I found him gliding in a lane near. 
Upon seeing me he ran away. I caught him, and on gaining ad- 
mission to the stables I found the hide, but not the carcase. The 
occupier, in reply to my question, said it had gone to the knacker's 
yard. To satisfy myself that the carcase had not gone for human 
food, I proceeded to the only two yards within some miles of the 
town and found that this information was untrue. A few days 
later I received information from which there was very little doubt 
that the carcase had gone for human food to a district a few miles 
away, and it is very probable that the carcase was affected with 
some organic disease. 

The difficulties of dealing with this illicit meat traffic are very 
great, and necessitate long watching of the class of persons who 
deal in ' slink ' meat. 

The reports of the Local Government Board contain 
numerous examples of the trade in unsound meat on a 
large scale. A co-operative society was found to be in 
possession of nearly 1| tons of offensively- smelling and 
tainted meat on premises where the manufacture of 
sausages was proceeding. The evidence revealed a par- 
ticularly disgusting condition of things, and the magistrates 
inflicted a fine of £20, with £10 : 10s. costs. A meat- vendor 
who sold unsound meat habitually was warned by the 
Sanitary Authority. The warning did not however act 
as a deterrent ; he was again detected in the act of selling 
such meat to different customers, and on proceedings being 
taken was fined £15 and £2 : 2s. costs. The Local Govern- 
ment Board speaks of this as a ' substantial ' penalty, 
but the consumers of the meat might take a different view ; 
they might think that a term of imprisonment would not 
have been amiss, and they might ask why the offender 


was permitted to escape in the earlier instances simply 
with k ' a warning." 

When we recall that during the War one of the largest 
firms of caterers in the country has been fined the maxi- 
mum amount for supplying unsound meat to the troops, 
the magistrate expressing the opinion that the negligence 
involved not only the employees, but also the managers 
of the firm; and that another large company was fined 
the maximum amount for supplying adulterated butter 
to troops, we see that patriotism weighs as little with 
dishonest traders as concern for Public Health. 

Meat is not the only article over which it is necessary 
to exercise vigilance. A manufacturer for instance was 
found deliberately using unsound jam, fat, and other 
articles in the preparation of confectionery. He is 
described as a ' wholesale and retail baker in a large way 
of business,' and was fined £15 and £2 : 2s. costs. 

When unsound food is submitted to a magistrate, the 
question for determination is whether it is fit for human 
consumption or not. Usually magistrates recognise the 
danger of unsound food and take a severe view of offences. 
Sometimes, however, their decisions are contrary to expert 
opinion and opposed to the public interest, an interesting 
example of which has been described in a circular issued 
by the Medical Officer of Health for Bermondsey. In 
June 1915 the Wharves and Food Inspector found eighty- 
two casks of imported butter rancid and unfit for human 
consumption. This opinion was confirmed by the Medical 
Officer of Health and the Public Analyst, who had found 
3*16 per cent of free fatty acids present, the normal amount 
in fresh butter being well under '5 per cent. A prosecu- 
tion was instituted, and for the defence it was urged that, 
while the butter was not fit to be sold over the counter, it 
could be used for making cakes and confectionery, in which 
its rancid taste and smell would be disguised by other 
flavourings. After examining the butter the magistrate 
decided that it was fit for human consumption, and the 
casks were released. 

It appears, therefore, that while a vendor may be 
summoned for having 1 per cent of water in his butter 



above the prescribed standard, he may have more than 
3 per cent of free fatty acids without committing an 
offence. The Medical Officer of Health for Bermondsey 
has declared that the War Office, Boards of Guardians, 
and other public authorities would refuse to accept such 
butter ; and only the general public fails to secure protection 
against food- stuffs made of impure or unsound materials 
whose rottenness is concealed by other flavourings. 

A case described in the report of the Local Government 
Board for Scotland for 1914 illustrates another way in 
which legal decisions may be opposed to the public interests. 
The carcase of a cow killed in the public slaughter-house 
of a burgh in the north of Scotland was found to be tuber- 
culous throughout. The veterinary surgeon condemned 
it, the owner of the carcase admitted that it was the 
' worst case of the kind ' he had ever seen, and orders 
were given that it should be buried. Nevertheless the 
owner removed the meat from the slaughter-house and 
distributed it in various directions throughout the com- 
munity. After legal proceedings involving the butcher, 
the veterinary surgeon, the Town Clerk, the Chief Con- 
stable, the Local Authority, and the Procurator-Fiscal, 
the matter was eventually referred to the Crown Office, 
who gave their opinion that there was a reasonable chance 
of securing a conviction against the butcher for obstruct- 
ing the Local Authority or Sanitary Inspector from carry- 
ing out their duties. Accordingly a prosecution was 
instituted by the Procurator-Fiscal in the Sheriff Court, 
where it was decided that removal of portions of a carcase 
while it was only liable to be seized and had not been 
actually carried away, did not amount to obstruction in 
terms of Section 163 of the Public Health Act. 

A pleasing practice described in the same report is 
that of ' blowing ' meat, which was formerly done by the 
mouth, but is now effected by a machine. Air is blown 
into the tissues which gives a false appearance of plump- 
ness to the meat. Besides being a direct fraud, the 
practice alters the appearance of the meat so as to increase 
the difficulty of detecting disease, and increases the danger 
of contamination by dirt, dust, and micro-organisms. 


Conditions under which Food is prepared 

The work of the Local Government Board in con- 
nection with inspection of food to be used by troops has 
brought to light another weakness in the scheme for pro- 
tecting the food of the community. Under ordinary 
circumstances the power of Sanitary Authorities to inspect 
and control the conditions under which food is prepared 
is very limited. The War Office however when making 
contracts for the supply of food, requires that the food 
shall be prepared under hygienic conditions ; and this 
stipulation has given the food inspectors opportunities 
of observing conditions which were previously denied to 
them. Wlule, speaking generally, the quality of the 
materials used in the preparation of food for the troops 
has been found to be good, the inspectors have had on 
many occasions to take exception to the conditions under 
which it was being prepared. To quote the Local Govern- 
ment Board Report : " While the conditions found in some 
6 of the principal food-preparing places concerned were 
' quite satisfactory, many instances have been met with in 
1 which manufacturers have not seen or appreciated the 
' necessity of observing ordinary rules of cleanliness in all 
6 operations connected with food preparation. It has 
' been quite common to find foods being prepared in rooms 
' littered with dirty rubbish, benches frequently have been 
' dirty and loaded with grease, and floors and walls cracked 
'- and uneven, thus harbouring dirt. The state of personal 
c cleanliness of the workers, also, frequently has left much 
' to be desired. Aprons and overalls, if worn at all, were 
' often filthy, and in some instances old and dirty sacking 
' was considered good enough for the work-people to wear 
' over their own clothes. ... As has already been indi- 
' cated, action in such cases has been possible only through 
' officials being in position to enforce War Office require- 
' ments, and it is to be feared that the improved standards 
' of cleanliness which have been secured will not be main- 
' tained by many of the firms when they are no longer 
' engaged on War Department work." 

If these were the conditions found in the premises of 


firms which had agreed to observe hygienic surroundings, 
and knew they were liable to inspection, it may be inferred 
that the conditions are worse in places for preparing food 
which are not under stipulation or control. The probability 
is that if we could see the dirt and adulterants in much of 
our food, there is very little that we should care to eat. Let 
any one who buys a glass of milk in a tea-shop imagine 
what it would look like if it had been water, and had gone 
through the processes and journeyings through which the 
milk has passed. Part of this is due, as the Local Govern- 
ment Board points out, to sheer ignorance of what constitute 
cleanly conditions. The shopkeeper takes care to protect 
dainty fabrics from dust and dirt by keeping them behind 
glass windows, but it is common to see butter, ham, and 
other articles of food intended to be eaten as they are, 
quite uncovered in shops which are anything but clean, 
or even exposed for sale outside in crowded and dirty 
streets, where particles from horse droppings and other filth 
in the roads may be blown upon them by every gust of 
wind. The costers' barrows, with their plates of shell-fish, 
or slushy mess sometimes termed * fresh -picked straw- 
berries,' are even worse. Inside some of the best shops 
and large stores we find pastries and sweets laid out on a 
counter by the side of which a throng of customers con- 
tinually passes. These conditions are not necessary, but 
so far as the writer knows there is only one large shop in 
London which keeps and displays its food-stuffs under 
really hygienic conditions. We hear a great deal now- 
adays about the necessity of educating mothers, but it is 
certain that some of this effort might with advantage be 
directed towards educating not only vendors of food-stuffs 
but also the general public, who are apparently quite 
satisfied to have their food prepared and sold under the 
conditions described. 

Patent and Proprietary Foods 

These widely -sold foods are objectionable mainly in 
consequence of the extravagant claims which are made for 
their value, and their unsuitability for the purposes for 


which they are advertised. Artificial foods for infants are 
probably the most pernicious. As shown by the analyses 
made by Mr. Julian Baker and Dr. Coutts for the Local 
Government Board, 1 a large proportion of these foods 
contain high percentages of starch ; in many the starch 
exists in practically an unchanged condition ; and the 
majority contain a very low percentage of fats. Such 
foods are unsuitable for young infants, and may cause 
serious illness ; nevertheless they are boomed by advertise- 
ments which are often little short of fraudulent. Pictures 
of Gargantuan babies fed on the food are pasted on the 
hoardings, and mothers are assured that only by taking 
the food will their children thrive. Condensed milks, con- 
taining a large proportion of cane-sugar and very little fat, 
are belauded to credulous women as entirely satisfactory 
substitutes for mothers' milk. Thus, while Public Health 
and Education Authorities are doing all they can to 
encourage breast-feeding, vendors of infants' foods and 
milks are allowed largely to nullify these efforts by spread- 
ing broadcast their unwarranted claims. In France, the 
Roussel law prohibits the administration of any solid food 
to infants under the age of twelve months without the 
express direction of a medical man. In Australia a 
regulation is general which demands that starch-containing 
foods shall bear a label with the words, ' Not suitable for 
infants under the age of six months ' ; but in this country 
no such safeguards exist. 2 

A further objection to these foods is their cost, which 
is generally out of all proportion to their value, a packet 
containing perhaps two pennyworth of flour being sold 
for a shilling or more. The poor are thus paying for the 
excessive advertising, with money which might be much 
better spent in buying natural food. 

Of proprietary foods for adults, probably those which 
are pushed with the most misleading statements are 
various meat extracts, often advertised with pictures of 
lusty oxen or Highland cattle. These substances consist 

1 Food Report*, No. 20. 

2 See " Proprietary Foods in Infant Feeding," by Hector Charles Cameron, 
M.D., Brit. Med. Journ., Aug. 21, 1915. 


of the salts, flavouring material, etc., of meat, but do not 
contain any meat fibre, albumin, or fat, though in some 
preparations small quantities of these are added to give 
the extract a certain food value. When made into solution 
with warm water they serve on appropriate occasions as 
useful stimulants, and perhaps do some good by lessening 
the sale of alcohol, but their food value is very small, and 
they produce neither heat nor energy. Nevertheless the 
public are led to believe that they are valuable and sus- 
taining foods ; and during recent months they have been 
widely advertised as enabling munition workers to endure 
heavy toil, and as the best present for soldiers in the 

No one would propose to prevent the trade in pro- 
prietary foods, but there seems little reason why advertise- 
ments of such foods should not be submitted before 
publication to a central Public Health authority, which 
should have power to delete any claims not in accordance 
with fact. 

Patent and Proprietary Medicines 

The whole question of the sale of patent and proprietary 
medicines has recently been investigated exhaustively by 
a Select Committee which issued its report in 1914, a 
report which is probably unequalled among Government 
publications as an exposure of commercial fraud, legisla- 
tive muddle, and shameless exploitation of credulity and 

The trade in proprietary remedies is very large and 
increasing, the receipts for medicine stamp duty having 
risen from £327,857 in 1912, and £328,319 in 1913, to 
£360,377 in 1914, a much larger increase than in any 
previous year, which suggests that the Insurance Act, 
owing to the importance attached in that measure to 
drugs, has actually stimulated the trade, despite the fact 
that insured persons now get medicines free from the 
doctors. The number of medicine duty stamps issued 
during the year ending March 31, 1914, was 44,427,166, 
estimated to represent sales exceeding the value of 


£3,200,000, and this is exclusive of large classes of medi- 
cines which, for various reasons, are not required to pay 
duty. Figures for individual businesses indicate the 
magnitude of the trade. The daily sale of a well-known 
pill amounts to more than a million ; the proprietors of a 
certain syrup pay upwards of £40,000 a year in wages 
only ; and several owners of much- advertised remedies 
have left fortunes exceeding £1,000,000. Enormous sums 
are spent on advertising. The proprietors of a ' medicated ' 
wine spend £50,000 a year for this purpose, and a well- 
known swindler, now deceased, is believed to have spent 
£20,000 a year in advertising an alcohol cure. The London 
Chamber of Commerce estimates that £2,000,000 is spent 
annually in this country on advertisements of proprietary 

The sale of secret remedies undoubtedly constitutes a 
grave and widespread public evil. Some of them contain 
powerful and dangerous drugs, which should only be taken 
on a doctor's prescription, and the so-called ' soothing 
powders ' may be particularly harmful to children. A 
much larger number, however, contain some common drug, 
very frequently a purgative, with colouring and flavour- 
ing agents; or consist of dilute solutions of substances 
possessing no medicinal value — at least in the amounts 
given — such as glycerine, citric acid, sulphurous acid, and 
sodium bicarbonate, flavoured with capsicum, pepper- 
mint, cinnamon, etc. These are sold with grossly fraudu- 
lent claims of their power of curing disease, at prices which 
are often several hundred times the cost of manufacture. 
Cures for consumption, diabetes, paralysis, locomotor 
ataxy, Bright's disease, lupus, fits, epilepsy, rupture, deaf- 
ness, diseases of the eye are advertised with stories of the 
discovery of a rare root in Central Africa, or of a philan- 
thropic clergyman who was profoundly impressed by the 
death of his young wife, etc. A " well-known London 
surgeon " promises a cure for cancer by natural means 
without operation, and supports his claim by testimony 
" from medical men in all parts of the world." Advertise- 
ments are accompanied by garbled extracts from the 
writings of deceased physicians of eminence, and by 


testimonials from persons in all ranks of society, many of 
which are quite genuine, but have clearly emanated from 
those unable to distinguish between post hoc and propter 
hoc. Sometimes puffs are inserted in the ordinary columns 
of the journals as items of interesting news. The result 
is that many thousands of ignorant persons buy these 
remedies when ill ; and if suffering from a serious disease, 
may postpone seeking skilled medical advice until grave 
harm has been done or a fatal termination is in- 
evitable. Persons with early tuberculosis have recourse 
to ' lung tonics,' and many a woman suffering from cancer 
of the breast has allowed the opportunity for a permanent 
cure to pass, while she has been applying inert ointments, 
or causing ulceration by using a caustic paste to destroy 
the ' roots ' of the growth. The habit of taking drugs 
becomes established, and many persons continually pur- 
chase ' blood purifiers,' ' uric acid solvents,' ' kidney 
pills,' ' headache cures,' and other nostrums. The waste 
of money in the purchase of these drugs by the working 
classes is very large. An inquiry made in 1909-1911 by 
the Board of Trade into the weekly personal expenditure 
of a number of wage-earning women and girls, showed 
that more than five times as much was paid to chemists 
as to doctors. The condition and complaints of these 
girls are indicated by the titles of the drugs purchased. 
' Blaud's pills,' ' soda - mint tablets,' ' throat pastilles,' 
and ' camphorated oil ' occur again and again, and tell 
a weary tale of struggle against ill-health. 

A particularly pernicious form is the sale of prepara- 
tions purporting to produce abortion. These are largely 
advertised, for some curious reason or other, in some of 
the Sunday journals, with statements which but thinly 
disguise their object. They are warranted to remove the 
" most stubborn cases of obstruction and irregularity," 
and are a " safe, certain, and speedy remedy," but are 
" on no account to be taken by ladies wishing to become 
mothers." Sometimes the revenue stamp which must be 
affixed to the box is cunningly represented as a guarantee : 
" My female specifics are Government stamped, without 
which they are a forgery." Such preparations are sold 


in various ' strengths,' the ' extra strong ' running up 
to 20s. a box, but the difference in the qualities does not 
extend farther than the label and the price. Most of 
these substances are inert and harmless, but some of them 
contain powerful drugs or strong purgatives which, if 
taken in large quantities, may cause serious illness. During 
recent years the practice of taking pills made of diachylon 
plaster or other compounds of lead has become frequent, 
and has led to numerous grave and even fatal cases of 
chronic lead-poisoning. The practice originated in the 
Midlands, and is now spreading to other parts of the 
country. The knowledge is conveyed from mother to 
mother, and some midwives of an inferior type appear 
also to be responsible. Many of the women who take these 
preparations are unaware of their dangerous properties, 
or even of the fact that they contain lead. 

Mischief is also done by the sale of ' medicated ' wines, 
many of which contain from 15 to 20 per cent or more of 
alcohol, and can be readily purchased from chemists and 
grocers. The report of the Select Committee says : 
" There can be no doubt that many persons acquire the 
" ' drink habit ' by taking these wines and preparations, 
" either knowing that they are alcoholic, since they can be 
" purchased and consumed without giving rise to a charge 
" of ' drinking,' or in ignorance that they are highly in- 
" toxicating liquors." Some of these preparations are not 
even called wine, such names as ' liquid peptonoids,' or 
' nutritive elixir,' concealing all suggestion of the fact 
that they contain alcohol. 1 A trifling amount of meat 
extract is added to some wines, which are then claimed to 
be nutritive. One well-known preparation is advertised 
as giving " a strength that is lasting because in each wine- 
glassful there is a standard amount of nutriment," and 
another is described as " the world's greatest tonic, restora- 
tive blood-maker, and nerve food." The pictures of 
languid invalids reclining on couches while doctor or 
nurse hands them a glass of one of these alcoholic concoc- 
tions are among the most objectionable of advertisements. 

1 Quite recent regulations now require the amount of alcohol in patent prepara- 
tions, etc., to be stated on the label. 


Some medicated wines contain cocaine, and there is 
reason to believe that the habit of taking this drug, which 
had recently assumed serious proportions in Paris, is now 
increasing in this country. 

Great difficulty exists in exposing to the public the 
fraudulence of this trade, owing to the reluctance of the 
newspapers to publish anything which reflects on the value 
or efficiency of secret remedies. It is estimated that 
a sum of more than £2,000,000 a year is spent upon adver- 
tisements in the Press, and most newspapers draw a 
considerable proportion of their income from this source, 
while a number of small provincial newspapers probably 
could not exist without their advertisements of secret 
remedies. The Select Committee point out that when the 
British Medical Association issued its volume entitled 
Secret Remedies, containing analyses, costs, etc., of a large 
number of proprietary medicines, not only was the volume 
not noticed editorially by most papers, but even advertise- 
ments were declined by many journals, some of them of 
the highest class. They also say : "A trial in Edinburgh, 
" in the course of which the judge described the business of 
" the proprietors of ' Bile Beans ' as based on unblushing 
" falsehood for the purpose of defrauding the public, was, 
" we were informed, with few exceptions not reported in 
" the Press, and the remedy still has a considerable sale." 
Even the medical Press is not entirely free from blame ; 
and one medical journal, which claims to have a con- 
siderable circulation though it would not be recognised 
as one of the leading organs, mixes with its letterpress 
scarcely distinguishable puffs of patent medicines and 
illustrations of appliances to prevent conception. 

The law relating to the sale of patent and proprietary 
medicines and its administration are described by the 
Select Committee as ' chaotic' The Statutes begin from 
1804, and are numerous, overlapping, and sometimes in- 
consistent ; the administration touches the Privy Council, 
the Home Office, the Local Government Board, the Patent 
Office, and the Board of Customs and Excise. Many 
curious anomalies exist. ' Cough mixture,' ' liver tonic,' 
and ' headache powder ' are dutiable, but ' chest mix- 


ture,' ' liver mixture ' and ' head powder ' are not. 
Smelling-salts pay duty, but asthma cigarettes do not. 
Identically the same substance is sold under a great 
variety of names, but if asked for under one name the 
chemist may not sell it under another. Almost the whole 
of this mass of law and administration exists, not for the 
purpose of protecting the public, but for the object of 
adding a relatively small sum to the revenue. There is 
no Department of State nor public officer charged with 
the duty of controlling the sale and advertisement of 
secret remedies in the interests of Public Health ; the 
Home Office and the Local Government Board are virtu- 
ally powerless in this respect ; and the powers of the 
Privy Council are practically restricted to scheduling 
powerful poisons. 

The Select Committee on Patent Medicines considered 
that legislation was urgently needed, and made a number 
of recommendations, which included control of the sale of 
patent and secret medicines by a Ministry of Health when 
that should be created, and meanwhile by the Local 
Government Board. The outbreak of war is perhaps 
sufficient reason why no action has been taken, but as the 
question pertains to no special Department, it will prob- 
ably provide another instance of those matters which are 
put aside year after year, simply because it is no one's 
business to be concerned with them. 

Unqualified Practice 

In this country any person, however ignorant, may 
undertake the treatment of disease. The law of medical 
registration does not do, and does not purport to do, 
more than provide a means whereby the public can dis- 
tinguish between persons professing medicine who are 
registered and recognised by law in virtue of their having 
undergone a specified medical training and passed certain 
examinations, and others who have had no such training 
or examination. Medical treatment is far older than 
medical law, and it is not probable that the community 
will ever restrict the practice of medicine exclusively to a 


professional class. Nor, indeed, would the medical pro- 
fession ask for this ; medicine has still much to discover ; 
and doctors are not infallible, and they would not be 
justified in demanding that the sick should be prohibited 
from seeking assistance from any but those who have 
gone through the prescribed training. But while practice 
by unregistered persons must be permitted, there is no 
reason why it should be associated with grave abuses. 
The community is justified in taking steps to protect the 
ignorant and credulous from false claims and fraudulent 
practices of unregistered persons ; while the doctors are 
entitled to ask that the distinction which the law has 
sought to make should be real, that their titles should not 
be usurped by unregistered persons, and that only registered 
doctors should be recognised by the State for official 

The Medical Act of 1858, which governs the use of 
medical titles, prohibits a person from wilfully and falsely 
using the title of Physician, Surgeon, etc., or any title or 
description implying that he is registered under this Act or 
that he is recognised by law as a Physician, Surgeon, etc. 
At first sight this section would appear to afford ample 
protection to registered medical men, but the words in 
italics have given rise to much dispute, and successive 
legal decisions have so reduced their application that now 
the spirit of the section, if not the letter, may be violated 
with impunity. Any person may call himself ' doctor,' 
since this has been held not to imply that he is registered ; 
and may publish circulars and advertisements relating to 
medical matters, from which the public is clearly intended 
to infer that he is a doctor of medicine. ' Dr.' Macaura, 
* Dr.' Bodie, and ' Dr.' Crippen afford instances of the 
use of this title. And with regard to the use of letters 
after the name, while ' M.D.' alone is held to be an in- 
fringement of the Act, any one may add ' M.D., U.S.A.,' 
though if this is meant to imply ' United States of 
America,' there is of course no university of that name. 
The result is that a large number of ignorant persons, 
even if they are aware that the person they consult is 
unregistered, believe that he is qualified in some special 


way to give medical or surgical advice. The medical 
profession, too, have a legitimate grievance in that their 
privileges are infringed. By law, only a registered medical 
man can give a certificate of death, but until quite recent 
years registrars were empowered to accept from other 
persons ' information ' concerning a death which amounted 
to a death certificate in all but name. Under the regu- 
lations made by the Insurance Commissioners, insured 
persons may be medically treated by unregistered persons, 
though there is nothing in the Act to justify this course, 
and the Royal Colleges have protested strongly against 
it. 1 The Commissioners have, however, considered them- 
selves bound by a verbal promise which was given in the 
House of Commons, but was not embodied in the Act. 

Some unregistered persons pose as qualified medical 
men, and treat all classes of diseases, or claim to be 
specialists in the treatment of cancer, consumption, 
venereal diseases, affections of the eye or deafness. Others, 
such as herbalists, bone-setters, and faith-healers, boldly 
distinguish themselves from medical men, and claim that 
their methods of treatment are superior, since they are 
not bound by the traditions of orthodoxy. Much prescrib- 
ing and treatment of minor illness is also done by chemists. 
That great harm is done by these persons has been shown 
again and again. The report of the Inquiry into Un- 
qualified Practice, made by the Privy Council in response 
to an appeal from the General Medical Council, gives 
numerous examples of grave and even fatal results due to 
ignorant treatment, and other instances have appeared 
in the public Press. Sometimes errors of diagnosis are 
made, but frequently there is no question that the patient 
is suffering from cancer, diabetes, consumption, or other 
deadly disease ; nevertheless he is persuaded to undergo 
a course of treatment which involves the purchase of 
quantities of costly drugs or instruments. Though all the 

1 The following resolution was passed by the Royal College of Physicians in 
1914 : " Hitherto none but duly qualified medical practitioners have been employed, 
as such, in any public capacity; and the College deplores that under an Act pro- 
fessing to promote the health of the nation, recognition should be given and pro- 
vision made for the payment of public money to a class of persons who have not 
obtained a legal qualification to practise medicine, and concerning whose medical 
knowledge there exists no sort of guarantee." 


time steadily getting worse, the patient is assured that he 
is rapidly improving, and tricks are played to convince 
him of the fact. In one instance portions of pig's entrails 
were shown to a woman to convince her that the cancer 
had come away from her breast. Sometimes the quack 
will continue to suck his victim like a vampire until death 
releases him from his clutches, but more often, having 
gone as far as he dare, he will let the sufferer pass under 
the care of a qualified practitioner in order that there may 
be no difficulty about the death certificate. 

A pernicious class consists of those who undertake the 
treatment of venereal diseases. According to the above- 
mentioned report, the treatment of venereal diseases in 
many large towns is to a considerable extent in the hands 
of unqualified persons. Chemists and herbalists frequently 
undertake the work, and the number of so-called specialists 
in venereal diseases appears to be increasing. The oppor- 
tunity for these practitioners is very great, owing to the 
fear of many sufferers of their condition becoming known, 
and their reluctance to consult their family doctor. These 
persons advertise a rapid and painless cure for all sexual 
ailments, ' loss of virility,' etc., with testimonials and 
hours of attendance. Sometimes they give instructions 
for the sufferer to make his own diagnosis, and describe 
perfectly natural phenomena as evidence of disease. They 
will even undertake to examine secretions. In one case 
the police, under an assumed name, sent to a man who 
advertised that he was principal of the ' British Health 
Institute,' a bottle of fluid consisting of tea, soap, and 
colouring matter, and received a reply that he was suffer- 
ing from internal catarrh, but was assured that : "I have 
every confidence that by following my treatment you should 
soon derive very considerable benefit." One medicament 
found on the premises of the ' Institute ' consisted of salt 
coloured pink with aniline dye. The influence of these 
practices upon Public Health is very injurious. The 
Royal Commission on Venereal Diseases say : " We have 
" no hesitation in stating that the effects of unqualified 
" practice in regard to venereal diseases are disastrous, and 
" that, in our opinion, the continued existence of unqualified 


" practice constitutes one of the principal hindrances to the 
" eradication of those diseases." As we have seen, action 
has now been taken to provide skilled treatment. 

Abortion-mongers are obliged largely to carry on their 
trade in secret, though they may advertise ' female reme- 
dies/ and they frequently associate the sale of Malthusian 
appliances with their business. In addition to the immense 
trade in pills, etc., there is no doubt that a great deal of 
instrumental interference is performed, particularly in the 
Midlands and northern counties. The cases which come 
to light owing to the death of the woman and the holding 
of a coroner's inquest, represent only a small fraction of 
the operations actually performed. Many abortionists 
now exercise a considerable degree of skill in their manipu- 
lations ; they are aware of the dangers, have some knowledge 
of anatomy, and employ antiseptics, thus substantially 
reducing the risk of a fatal termination, though their 
efforts may be followed by serious illness, and perhaps 
permanent ill-health. Much interesting information relat- 
ing to abortionists will be found in an article, " Criminal 
Abortion and Abortifacients," by Dr. W. F. J. Whitley, 
in Public Health of February 1915. 

Another type of bogus doctor relies more upon appeal- 
ing to a whole class than to individual patients, and makes 
his profit by the sale of some appliance— an ' electric ' 
belt, a ' vibrator,' or an ear-drum. These things may be 
advertised in the Press, but often in addition the proprietor 
travels round the country, widely advertises his visit to a 
town, and holds huge meetings, at which a pretence is 
made of examining patients then and there, and numbers 
of the appliances are sold. One of these quacks, after 
holding meetings which filled the Albert Hall, not satisfied 
with his gains in this country, started his practices in Paris, 
where, under a sterner law, he was promptly arrested and 
sentenced to imprisonment. These appliances are bought 
by the more ignorant members of the community, and in 
many an agricultural labourer's cottage a vibrator or a 
useless ear instrument will be found, perhaps purchased 
for several guineas out of wages of 14s. a week. 



Central administrative authorities — Local administrative authorities — 
The evolution of the Public Health services — Administration of sana- 
torium benefit — Administrative authorities and statistics — The dis- 
couragement of the present system. 

The Public Health services in this country are administered 
centrally by nearly a dozen independent and uncoordinated 
Departments, Boards, and Councils ; and locally by nearly 
as many local authorities. Before examining the growth 
and effects of this system it may be useful to give a list of 
the authorities concerned. 

Central Administrative Authorities 

The Local Government Board. — This office contains two 
separate and distinct medical departments, one for Poor 
Law and the other for general Public Health purposes. 
The Chief Medical Inspector for Poor Law purposes 
exercises control over the medical activities of Boards of 
Guardians, and is concerned with the central administra- 
tion of the vaccination laws. The Chief Medical Officer 
to the Board advises on the issue of orders and instruction 
to Local Sanitary Authorities on Public Health matters, 
such as drainage, sanatoria, and maternity centres ; is 
responsible for special medical inspection in relation to 
infectious diseases and epidemics, defective housing, 
adulteration of food, etc. ; and conducts or arranges for 
scientific investigation in matters of hygiene. 

Tlve General Register Office addresses its annual report 
to the President of the Local Government Board, but other- 



wise seems to have no connection with that Department. 
It compiles the national vital statistics, and issues the 
annual report on Births, Deaths, and Marriages, which 
every year contains a valuable dissertation on the dis- 
tribution and principal causes of deaths. 

The Home Office supervises sanitary conditions in 
factories ; controls dangerous trades ; has duties in con- 
nection with the Mental Deficiency Act ; and is concerned 
with the prison medical service and inebriety. This Office 
also appoints Medical Referees and Certifying Factory 
Surgeons under the Workmen's Compensation Act. 

The Board of Education administers the Acts for the 
medical inspection and treatment of school children, and 
controls grants in aid of schools for mothers for instruction 
in infant care and welfare. 

The Treasury — though without a medical adviser — 
exercises important Public Health duties under the 
National Insurance Act. It determines whether extra 
expenditure upon medical benefit is reasonable or not ; 
gives its sanction before certain exceptional expendi- 
ture upon sanatorium benefit is incurred ; and has a con- 
trolling voice in determining what diseases other than 
tuberculosis shall be medically treated under sanatorium 

The National Insurance Commission administers the 
Insurance Act. There is a separate Commission for each 
of the four divisions of the United Kingdom, which are 
more or less brought into coordination by a fifth body, 
the Joint Committee. 

The Privy Council has duties in connection with the 
General Medical Council, the Central Midwives Board, and 
the Pharmaceutical Society. As an example of the Privy 
Council's activities in Public Health, reference may be 
made to the report it issued in 1910 on the " Practice of 
Medicine and Surgery by Unqualified Persons in the United 
Kingdom," though the information upon which the report 
was based was collected vicariously through the Local 
Government Board. 

The Board of Trade appoints medical inspectors to 
examine seamen in ports ; has duties in connection with 



sickness among emigrants ; and looks after the health of 
crews in certain particulars. It is of great interest to note 
that the Board has issued a book, the Ship Captain's 
Medical Guide, which all merchant ships must carry, and 
which contains instructions on the prophylactic measures 
against venereal disease referred to in an earlier chapter ; 
and that since 1911 it has been supplying merchant ships 
with the medicaments necessary for this purpose. 1 Thus 
the Board of Trade is conveying to seamen, and indirectly 
to the general public, knowledge of preventive methods 
which are ignored completely in the report of the Royal 
Commission on Venereal Diseases, and in the reports on 
Public Health of the Local Government Board. 

The Board of Agriculture prescribes, or may prescribe, 
the standards for milk, cream, butter and cheese ; issues 
the ' Sale of Milk Regulations ' ; and has power to inspect 
and register premises for milk-blending and margarine- 

The Colonial Office investigates or assists investigations 
of tropical diseases, and publishes reports thereon. The 
Board of Customs and Excise has duties in connection with 
the sale of patent and proprietary foods and remedies. 

The preceding authorities are Government Depart- 
ments, and are not concerned exclusively with Public 
Health. In addition the following central authorities 
discharge important duties in connection with Public 
Health :— 

The Board of Control, through the Commissioners in 
Lunacy, exercises general control over the supervision and 
protection of mentally defective persons, and the manage- 
ment of lunatic asylums, and appoints guardians and 
visitors of certified lunatics. 

The Ministry of Pensions exercises various functions 
in connection with the care and training of disabled 

The General Medical Council keeps the register of 
medical practitioners, superintends the standard of 
examinations for medical qualifications, and exercises 

1 See the evidence of Dr. Burland and Mr. Shepherd before the Royal 
Commission on Venereal Diseases. Appendix to Final Report, vol. ii. 


disciplinary control over the medical profession in pro- 
fessional matters. This body also publishes the British 
Pharmacopoeia, the volume which prescribes the standard 
strengths of drugs and the usual doses for administration, 
a new edition of which has just appeared after a lapse of 
fifteen years. 

The Central Midwives Board maintains the register of 
midwives, lays down regulations for their conduct of cases, 
and conducts examinations in midwifery for midwives. 

The Pharmaceutical Society examines and registers 
chemists under the Pharmacy Acts, and advises the Privy 
Council on the control of the sale of poisons. 

The preceding are all statutory authorities for England, 
and most of them have their counterparts in Scotland and 
Ireland. But the list by no means exhausts the bodies 
which do in fact influence Public Health affairs. Large 
and active Societies, such as those for the prevention of 
tuberculosis, venereal diseases, infant mortality, inebriety, 
etc. etc., investigate Public Health questions, issue reports 
which help to form public opinion, and are sometimes the 
means of securing the appointment of Royal Commissions, 
and of initiating legislation. To these must be added the 
large charitable organisations, such as King Edward's 
Hospital Fund and other hospital funds, the Charity 
Organisation Society, maternity charities, nursing associa- 
tions, social service leagues, etc., which annually disburse 
sums amounting to several millions in the interests of 
Public Health. 

Local Administrative Authorities 

In local administration we find a similar multiplicity 
of authorities, the principal bodies engaged in Public 
Health work being the following : — 

The Local Sanitary Authority. — In County Boroughs 
this is the Borough Council. In Urban and Rural Districts 
it is the Urban or Rural District Council, though certain 
duties are discharged for the County as a whole (exclusive 
of the County Boroughs) by the County Council. The 
chief Public Health duties of a Local Sanitary Authority 


are connected with infectious diseases, tuberculosis, housing, 
scavenging, drainage, adulteration of food, meat inspec- 
tion, milk supply, health visiting, etc. These are carried 
out under the advice of the Medical Officer of Health 
who is assisted by a staff of inspectors and health visitors. 

The Board of Guardians maintains infirmaries for sick 
paupers ; provides outdoor medical relief through a staff 
of Poor Law Medical Officers ; and undertakes public 

The Insurance Committee administers medical benefit 
under the Insurance Act, but must consult or act in con- 
junction with a number of other bodies, such as the Medical 
Benefit Sub-Committee, the Local Medical Committee, the 
Panel Committee, and the Pharmaceutical Committee. 
Sanatorium benefit is administered by a combination of 
the Insurance Committee and Local Authority, which has 
led to endless confusion and delay. Sickness and maternity 
benefit are administered by Approved Societies, except for 
deposit contributors, who come under the Insurance 

The Local Education Authority, which is the Local 
Authority acting through the Education Committee, pro- 
vides for the medical inspection and to some extent for 
the treatment of school children, and has duties in con- 
nection with schools for mothers. 

The Coroner inquires into deaths from unnatural 
causes. His inquests upon deaths from accidents in 
factories, etc., poisoning by trade processes, neglect, and 
other preventable causes are important from the Public 
Health point of view, and the accuracy of his investigations 
has an appreciable effect on the national vital statistics, 
since more than 10 per cent of all deaths come under the 
purview of coroners. 

The Magistrates and Justices are in effect in some of 
their duties Public Health officers, for they may be called 
upon to determine complex questions in relation to adulter- 
ation of food or condemnation of meat or standards of 
milk, and whether food is prejudicial to health or is of the 
nature and quality demanded. 

Besides the statutory authorities enumerated, Hospitals, 


Provident Dispensaries, Care Committees, District Nurses, 
Guilds of Health, and other private agencies are all en- 
gaged locally in important Public Health work. 

In London, administration is further complicated by 
the division of power between the London County Council 
and the twenty-eight Metropolitan Boroughs and the Cor- 
poration of the City. Other authorities peculiar to London 
or its vicinity are the Metropolitan Asylums Board ; the 
Metropolitan Water Board, which is responsible for the 
maintenance and purity of the water-supply, though the 
Thames Conservancy Commission exercises powers to 
prevent pollution of the river ; and the Port of London 
Sanitary Authority, a department of the Corporation of 
the City which supervises the sanitary condition of 
shipping and the Port of London generally. 

The Evolution of the Public Health Services 

This multiplicity of authorities is a result of the piece- 
meal way in which Public Health affairs have been dealt 
with in this country. Except for the general sanitary 
services, we have never provided for the needs of the 
country as a whole, but only for isolated groups, paupers 
school children, insured persons, etc. ; and — except for a 
brief interval in the middle of the nineteenth century — we 
have never had one central authority definitely charged 
with the protection of Public Health without other duties. 
As each new Act has been passed, its administration has 
been either thrust upon an existing Department, perhaps 
created originally for quite other purposes, or has been 
assigned to a new authority created ad hoc. We may 
learn several lessons by noticing some instances of these 

The original object of the Poor Laws was mainly 
the repression of crime and vagrancy. The Statutes of 
Elizabeth and enactments up to the eighteenth century 
refer again and again to " rogues, vagabonds, and sturdy 
beggars" ; and such persons might be whipped, branded, 
set in the stocks, or even hanged. The harsher laws were 
only gradually replaced by more humane legislation, and 


the Poor Law authorities slowly assumed their important 
function of providing for the sick and infirm poor. Poor 
Law Unions and Boards of Guardians were created by 
the Act of 1834, and later years saw the growth of the 
infirmary system and other forms of medical relief. How 
completely the Poor Laws have changed their character 
since the days when they existed mainly for the suppression 
of vagrancy, may be realised from an analysis of the 762,196 
persons in receipt of relief on January 1, 1915. Of these 
415,449, or 54*5 per cent, were definitely suffering from 
sickness, accident or mental or bodily infirmity, and 
223,062 others were children. The remainder included per- 
sons over seventy years of age, persons relieved on account 
of sickness or infirmity of wife or child, persons weak or 
feeble from premature senility or other circumstances, 
widows, wives living apart from their husbands, etc. The 
class who were, broadly speaking, in health and free from 
mental infirmity, but were more or less inefficient, 
numbered less than 20,000. 

The Poor Law system, with its great infirmaries scattered 
all over the country, is in fact our largest public pro- 
vision of medical treatment and care for the poorer 
classes, particularly for those suffering from chronic ill- 
ness or permanent incapacity. It is therefore much to 
be regretted that a prejudice exists among the working 
classes against accepting this form of assistance, a prejudice 
which is undoubtedly inherited from the time when the 
Poor Laws were so closely associated with the repression 
of crime and vagrancy. This hostile sentiment is not 
manifested towards the voluntary hospitals, although they 
limit their assistance mainly to the poorer classes ; and the 
view that this attitude should be encouraged as a sign of 
healthy independence is only put forward by those ignor- 
ant of the facts, and still possessed by the ' sturdy beggar ' 
theory. When the Insurance Act was under consideration, 
an opportunity existed of sweeping away this stigma by 
incorporating the Poor Law medical system into a general 
public medical service, but unfortunately the opposite step 
was foolishly taken, and Poor Law authorities were rigidly 
excluded from those with whom Insurance Committees 


might make arrangements for sanatorium benefit. Then, 
after emphasising the stigma of pauperism, the Insurance 
Act provides no alternative but the Poor Law infirmaries 
for many thousands of tuberculous insured persons. 

But while the Poor Law medical service is restricted 
to indigent persons, the local administration of the vaccina- 
tion laws by the Poor Law authorities for all classes of the 
community affords an illustration of a duty which has no 
relation whatever to pauperism. When, in 1840, vaccina- 
tion was first provided at the public cost, the old Poor Law 
Board (with no medical officer in its service) was made the 
central authority, and local administration was entrusted 
to Boards of Guardians and overseers, for at that time there 
was no Local Sanitary Authority in existence. But since 
that date there have been many changes. Vaccination was 
made compulsory in 1853 ; the Poor Law Board has been 
swept away, and Local Sanitary Authorities created ; but 
though in earlier years the service was bad and there were 
flagrant instances of disastrous maltreatment, the Boards 
of Guardians have ever since continued to provide or 
supervise vaccination among all classes of the community. 

The Metropolitan Asylums Board is an offshoot from 
the Poor Law, which now occupies a distinctly anomalous 
position. It was created in 1867 to provide for the recep- 
tion and relief of the sick, insane, infirm, and other classes 
of the poor in London. By an Act of 1883, the civil 
disabilities which had till then attached to admission to 
the Board's hospitals were removed ; and by later Acts the 
Board was authorised to admit non-pauper cases of fever. 
Now the fever hospitals are used for the reception of 
patients of all social classes, and no trace of the stigma of 
pauperism attaches to admission thereto, although the 
Board is still legally a Poor Law authority. We may 
note here the extraordinary position to which this gave 
rise under the Insurance Act. We have seen that this 
,Act requires arrangements for sanatorium benefit to be 
made with bodies other than Poor Law authorities. When, 
after the passing of the Act, arrangements for London 
were considered, it was at once realised that the Metro- 
politan Asylums Board, with its well-equipped hospitals 


and sanatoria and buildings capable of being converted 
into sanatoria, was eminently the appropriate body with 
which to make arrangements. Indeed without its help 
there was no hope of making reasonable provision in 
London for a long time. Then arose the question : was 
the Board a ' Poor Law Authority ' ? No guidance was 
to be found in the Act or in the Parliamentary debates, 
and in fact it seems clear that Parliament had forgotten 
either the existence of the Board or its anomalous char- 
acter. The managers of the Board themselves say in 
their report for 1912 : " There is no doubt that the 
special position in London of the Metropolitan Asylums 
Board as in fact a Public Health and infectious hospital 
authority, was lost sight of." After prolonged discussion 
and taking of legal opinion, it was finally decided that the 
London Insurance Committee was prohibited from making 
arrangements with the Board. It was however held that 
the Insurance Committee might make arrangements with 
the London County Council, while the Council in its turn 
could make arrangements with the Metropolitan Asylums 
Board, and this was done, thus arriving at the end desired 
by a circuitous route. Then a year later, in the amending 
Act of 1913 the London Insurance Committee was authorised 
to enter directly into arrangements with the Board ; from 
which it may be inferred that Parliament, if it had realised 
the position, would not have excluded the Board in the 
original Act. We may admire the ingenuity with which 
the administrative authorities circumvented the expressed 
intention of the Act, but we could not have a better lesson 
in the need for expert knowledge in Parliament when 
Public Health measures are under consideration, than the 
fact that this body, in a debate on the provision of sana- 
toria for the tuberculous, forgot either the existence or the 
anomalous character of the largest local authority in the 
country specifically charged with the duty of providing 
hospitals for infectious diseases, and actually maintaining 
sanatoria for tuberculosis at the time. 

The Coroner affords another example of an interesting 
change of function. Though not usually recognised as a 
Public Health official, he does in fact conduct many 


inquiries into deaths which closely touch Public Health 
matters. These duties are indeed more important than 
those connected with the detection of crime, which are 
for all practical purposes discharged by the police and 
magistrates ; the police collecting the information upon 
which the Coroner acts, while, if the inquest verdict and 
magistrates' decision are not the same, the criminal courts 
are almost invariably guided by the latter. The Coroner, 
however, who dates from the twelfth century, was origin- 
ally a revenue officer of the Crown, and was charged with 
the duty of confiscating the goods of criminals, taking 
possession of wrecks and seizing treasure-trove, a duty 
which still remains. He inquired into deaths for the 
purpose of ascertaining whether the deceased was an out- 
law or felon or suicide, in which case his property escheated 
to the Crown. 1 Escheat however has been abolished, 
and the tax-collecting functions of the Coroner have long 
disappeared, but the ancient machinery with its obligation 
upon the Coroner to hold land in his district lest he might 
abscond with the proceeds of his inquiries, its jury of 
' good and lawful ' men, and its ' view,' the object of 
which was to make sure that there actually was a body 
present, still remain to serve a radically different purpose. 
It is obvious that if we were now for the first time 
providing for the investigation of deaths from unnatural 
causes we should never dream of setting up the present 
machinery. The Coroner is not necessarily a medical 
man, and he need not and often does not call medical 
evidence ; his procedure is not suitable for a scientific 
inquiry ; and the final responsibility rests with a jury 
usually composed of artisans. ' Riders ' are merely ex- 
pressions of opinion which involve no legal consequences, 
and if abuses are detected, the Coroner has no machinery 
for bringing pressure to bear upon those responsible. 
Under these circumstances it is not surprising that verdicts 
are often palpably absurd, and serious errors are made in 
medical and scientific matters, perhaps the greatest of 

1 Pepys gives a very interesting pieture of an inquest in the seventeenth century, 
and of the devices which were adopted by relatives to defeat this harsh law, in his 
account of the inquest. 


which is the cruel injustice inflicted annually upon some 
hundreds of mothers who are informed, after a superficial 
investigation, that they have caused the death of their 
infants by ' overlaying ' them in bed. If these deaths 
were the subject of efficient inquiry, there is strong reason 
to believe that the great bulk of them would be found to 
have been due to natural causes. 1 

It is of interest to recall that at one time we had 
a central Public Health Authority which distinctly 
approached a Ministry of Health, and would probably 
have developed into such a Ministry had it been given fair 
opportunity. This was the General Board of Health 
created in 1848 in consequence of the frequency of epi- 
demics and the insanitary state of the country generally, 
which had been revealed in the reports of the Poor Law 
Commissioners. The new Board numbered among its 
members eminent men, such as Chadwick, Shaftesbury, 
and Southwood Smith, and did much useful work, particu- 
larly in the direction of removing refuse and improving 
drainage. But it worked under great difficulties : its 
existence was precarious, as it had only been appointed 
for a limited period ; its executive powers were restricted ; 
and it was not even authorised to appoint a medical officer 
until two years after its formation. The labours of the 
Board to improve sanitation aroused bitter hostility 
among vested interests, and the Board was also virulently 
attacked by those who, without knowledge of sanitary 
science, assumed the role of authorities and upheld the 
orthodoxy of the period. 2 In 1858 the Board was swept 

1 Justification for this statement will be found in An Inquiry into the Statistics 
of Deaths from Violence, by the author, 1915. Briefly, the reasons for the view 
expressed are : that there is no constant relation between overcrowding and deaths 
from overlying ; that the rural death-rate is far smaller than the urban death-rate, 
the decrease being much greater in proportion than the decrease in overcrowding ; 
that there is a marked seasonal variation in these deaths, the number declin- 
ing in summer and rising in winter ; that this variation agrees precisely with that 
of deaths from broncho-pneumonia, infantile convulsions, and atrophy, conditions 
presenting post-mortem appearances very similar or actually undistinguishable 
from those of overlying ; and that when the post-mortems are performed by expert 
pathologists, overlying is very rarely found to be the cause of death. 

2 Herbert Spencer, for example, said : " These impatiently agitated schemes 
for improving our sanitary condition by Act of Parliament are needless, inasmuch 
as there are already efficient influences at work gradually accomplishing every 
desideratum " ; and of the Board of Health he wrote : " It had more than a year's 
notice that the cholera was on its way here. . . . Well, what was the first step which 


away and its medical duties were divided between the 
Privy Council and the Home Office. Sir John Simon has 
described the abolition of the Board as a ' catastrophe.' 
He says : " An earnest, powerful endeavour had mis- 
" carried. ... In our sanitary case, too, the immediate 
" failure was only part of what had to be regretted. For 
" the invectives which had been meant to destroy the Board 
" had been too angry in their aim not to do much collateral 
" damage ; and they continued to operate for several years 
" on a considerable scale, in maintaining suspicion and 
" prejudice against sanitary proposals and those who made 
"them." 1 

The Local Government Board was created in 1871 as 
a result of the report of the Royal Sanitary Commission 
of 1868, which demonstrated the confusion into which the 
administration of Public Health affairs had fallen. To 
the new authority were transferred the duties and staffs 
of the Poor Law Board and the General Register Office, 
and most of the medical duties of the Privy Council, 
though some of the latter remain to be discharged by that 
body, resembling the ' vestigial structures ' of biologists. 
The union of authorities under the Local Government 
Board was however more in name than in fact, for the 
Registrar- General and the Poor Law and Public Health 
branches have always remained independent ; and ever 
since the Local Government Board was created, we have 
been re-establishing the old confusion by assigning medical 
duties to other offices, or creating new authorities for 

might have been looked for from it ? Shall we not say the suppression of intra- 
mural interments ? Burying the dead in the midst of the living was manifestly 
hurtful ; the evils attendant on the practice were universally recognised ; and to 
put it down required little more than a simple exercise of authority. If the Board 
of Health believed itself possessed of authority sufficient for this, why did it not 
use that authority when the advent of the epidemic was rumoured ? If it thought 
its authority not great enough (which can hardly be, remembering what it ulti- 
mately did) then why did it not obtain more ? Instead of taking either of these 
steps, however, it occupied itself in considering future modes of water-supply and 
devising systems of drainage. ... As was said by a speaker at one of the medical 
meetings held during the height of the cholera, ' the Commissioners of Public 
Health had adopted the very means likely to produce that complaint. Instead of 
taking their measures years ago, they had stirred up all sorts of abominations now. 
They had removed dunghills and cesspools and added fuel tenfold to the fire that 
existed.' " — Social Statics. 

Later knowledge has of course shown that the Board was entirely right in the 
measures it adopted, but it was clearly in advance of its time. 
1 English Sanitary Institutions, 1890. 


special purposes. It may be of interest to examine some 
examples of the complexity of administration to which the 
constant multiplying of authorities has now led. 

The Administration of Sanatorium Benefit 

The central administration of this benefit is divided 
among three Government Offices : the Insurance Com- 
missioners, who exercise control over the arrangements 
made by Insurance Committees ; the Local Government 
Board, which is charged with the duty of inspecting and 
approving sanatoria and dispensaries, and of approving 
the appointments of tuberculosis officers ; and the 
Treasury, which assents, if it thinks fit, to expenditure in 
excess of that provided by the Act, and must also approve 
proposals to treat diseases other than tuberculosis under 
sanatorium benefit. This division of authority greatly 
complicates administration, but the public do not become 
familiar with the conferences, committees, reports, etc., 
rendered necessary, since they affect mainly the internal 
working of the offices. Occasionally however it is possible 
to detect in the official reports issued by the Departments 
discreetly-worded evidence of acute difference of opinion 
which must have been productive of difficulty. The 
report of the Local Government Board for 1913-14, for 
instance, points out that while it is the duty of an 
Insurance Committee to decide whether an insured person 
should be recommended for sanatorium benefit, the 
Insurance Act does not require the Committee to deter- 
mine the form of treatment he is to receive ; and it shows 
further that many difficulties would have been avoided if 
it had been left to the tuberculosis officer to decide whether 
the applicant should receive sanatorium, hospital, or 
dispensary treatment, since he is the expert medical officer, 
and could determine the appropriate form of treatment 
on medical grounds. The Insurance Commissioners, on 
the other hand, hold that Insurance Committees must 
determine the form of treatment, and could not properly 
delegate this discretion to the tuberculosis officer, their 
reason apparently being fear lest the tuberculosis officer 


should recommend too many persons for sanatorium treat- 
ment. The view of the Commissioners prevailed, but it 
is quite clear that the interests of the community were 
sacrificed thereby. 

Locally, similar complexity exists. The Insurance 
Committee recommends insured persons for benefit and 
pays a contribution in respect of their treatment in sana- 
toria ; but the Local Authority provides the sanatoria and 
dispensaries, and appoints the tuberculosis officers ; while 
in London the position is further complicated by the 
powers and duties of the London County Council and the 
Metropolitan Asylums Board. Local arrangements have 
to be approved both by the Insurance Commissioners and 
the Local Government Board, and in many instances years 
of negotiation have preceded the final approval and 
adoption of a local scheme, while the money provided by 
Parliament for the relief of sufferers remains unspent. 
The amount allocated to England for grants in aid of 
sanatoria under the Finance Act of 1911 was £1,116,156, 
but up to June 1914 only £232,054 out of that sum had 
been promised to Local Authorities, and only £62,026 had 
actually been paid. 1 If the hardships tell upon those 
responsible for the confusion and delay, it would be deserved 
Nemesis, but unfortunately it is borne by many poor and 
inarticulate persons in desperate need of assistance. The 
number of beds is slowly increasing, but even with the aid 
of the voluntary hospitals and Poor Law infirmaries, and 
shortening of periods of residence in sanatoria, the accom- 
modation is insufficient, and many sick persons are waiting 
for admission to the promised homes. 

We may note another direction in connection with 
sanatorium treatment in which Parliament showed itself 
hopelessly lacking in appreciation of administrative diffi- 
culties. The Act provides that diseases other than 
tuberculosis can, on the recommendation of the Local 
Government Board, with the approval of the Treasury, be 
specially treated under sanatorium benefit " in sanatoria 
or other institutions or otherwise." To the inexperienced 
it may seem a simple matter to add other diseases when 

1 Forty-third Annual Report of the Local Government Board. 


once a scheme for tuberculosis is in satisfactory work- 
ing order, but those who have knowledge of administra- 
tion will appreciate the immense difficulties in the way. 
New contracts and new arrangements would be required 
with Insurance Committees, Local Authorities, Approved 
Societies, doctors and chemists. Special statistics would 
be demanded in order that new estimates of cost might be 
obtained. Volumes of circulars, orders and instructions 
would be issued, and every step would necessitate con- 
sideration by committees and conferences, the reconciling 
of different authorities, and the satisfying of vested 
interests. No doubt the Departments concerned would 
cheerfully undertake the task, but the public should 
realise that it is proceedings of this kind which demand 
the services of so many thousand clerks and officials, and 
so enormously increase the cost of administration. Accord- 
ing to the statement of Mr. Roberts, the present Chairman 
of the Joint Committee, it costs £600 merely to call the 
Advisory Committee together for one meeting. It is 
significant to note that the Local Government Board in 
the new arrangements for the treatment of venereal 
disease has not availed itself of the machinery theoretically 
available, by adding syphilis to the diseases treated under 
sanatorium benefit (which can be extended to non-insured 
persons), but has gone direct to the Local Authorities. 

Administration in Connection with Maternal 
and Infant Welfare 

Let us consider as another illustration of complexity 
in administration, the authorities concerned with the 
welfare of the mother and infant. The pregnant woman, 
if an industrial worker, is subject to laws restricting 
employment which are administered by the Home Office. 
At her confinement, if insured, she receives maternity 
benefit through her Approved Society ; if she is a pauper 
she may receive attendance through the Board of Guardians, 
while the midwife who attends her is subject to regulations 
made by the Central Midwives Board. The birth of the 
infant must be notified to the Medical Officer of Health, 


but it must be registered at the office of the local Registrar, 
and the Board of Guardians again steps in to see that the 
child is vaccinated. If the child is put out to nurse, the 
person who undertakes its care is subject to supervision by 
the Local Authority. If the mother wishes for advice or 
help in the care of her baby she may go to a ' school for 
mothers ' which is under the Education Authorities, or to 
an ' infant welfare centre ' under the control of the Local 
Authority and assisted by grants from the Local Govern- 
ment Board, and either of these institutions may send a 
health visitor to advise her as soon as the infant is born. 1 

It is of some interest to compile a list of inspectors and 
officials from whom a working-class mother with a family 
of children may now receive visits. The list includes the 
Medical Officer of Health, the Sanitary Inspector, the 
Housing Inspector, the Health Visitor, the School Attendance 
Officer, the School Nurse, the District Nurse, a Member of 
the School Care Committee, the Sick Visitor or agent of 
her Approved Society, the Insurance Inspector, and in 
cases of poverty the Relieving Officer, and perhaps a repre- 
sentative from the Charity Organisation Society. It is 
well known that this continual series of inspections among 
the working classes has given rise to a widespread feeling 
of irritation, and a sense of infringement of privacy. The 
most recent movement is one for notification of pregnancy, 
and already certain Local Authorities {e.g. at Nottingham 
and Huddersfield) have instituted a system of such notifica- 
tions, though it is not clear under what powers they have 
acted. If the visits of these inspectors and officials were 
productive of proportionate benefit a great deal could be 
said in their defence, but it is doubtful whether the whole 
system is having any appreciable effect in improving the 

1 In the matter of infant welfare the Board of Education and the Local Govern- 
ment Board are doing essentially the same work, and in the sections of their Annual 
Reports dealing with infant welfare they cover much the same ground. It is well 
known that this needless overlapping caused a disagreement between the two offices 
which led to a long delay before something approaching a working scheme was 
devised. The chief difference between the two sets of institutions is that while 
those assisted by the Local Government Board may provide treatment, the Board 
of Education centres are ' primarily educational,' the provision of medical and 
surgical advice and treatment being only ' incidental.' But, as Mrs. Acland has 
said : " When Mrs. Smith's baby begins to put on weight, who shall say whether we 
rejoice primarily because that means an improvement in Mrs. Smith's education 
or in the baby's health ? " 


health of the working classes or reducing the death-rate. 
With the exception perhaps of the sanitary inspector, they 
do little or nothing to improve the environment ; they do 
not provide healthy conditions of life or efficient medical 
attendance, or lying-in homes for mothers. As Mr. G. K. 
Chesterton has said, "they only move persons from 
Schedule A to Schedule B," while they lead the poor to 
feel that their liberty is infringed in a way the rich would 
not tolerate. 

Many other instances could be given of the wearisome 
delays and confusion which this system of administration 
involves. There is, for example, the dust-siding at East 
Dulwich station, immediately adjacent to the Southwark 
Infirmary, instalments of the story of which have been 
appearing in the public Press since 1913. The Guardians 
alleged that dust was blown into the children's wards and 
set up enteritis, and the dispute has involved inspections 
and reports by four medical experts, — the Medical Officer 
of Health, the Medical Superintendent of the Infirmary, the 
Medical Inspector of the Local Government Board, and 
the Medical Officer of a Children's Hospital, while negotia- 
tions between the Guardians, the Borough Council, the 
Local Government Board, and the London County Council 
had extended over two years without a settlement having 
been reached at the time the last report was published. 

Some of the disputes between overlapping authorities 
terminate in an agreement after more or less protracted 
negotiations ; others end by the aggrieved authority be- 
coming weary of the proceedings and letting the matter 
drop ; but the most absurd termination, from the public 
point of view, is in litigation between the authorities. We 
have had examples of Insurance Committees taking legal 
action against Insurance Commissioners ; of the London 
County Council proceeding against Borough Councils ; and 
of Boards of Guardians threatening the Metropolitan 
Asylums Board. All these bodies are servants of the 
public, they are supposed to be acting in the interests of 
the public, and the public pays for their litigation which- 
ever side wins. In the present chaos, litigation is no 
doubt sometimes unavoidable, but the situation is as 


absurd as if a householder were compelled to pay for 
litigation between his cook and his housemaid as to who 
should clean his knives or boots. 

Administrative Authorities and Statistics 

The lack of coordination among Government Depart- 
ments is almost incredible to those who have not had 
actual experience of their internal working. There are 
instances of one Department laboriously setting to work 
to collect information on a subject, full details of which 
are in possession of another Department, and have perhaps 
actually been published ; of two Departments inde- 
pendently making precisely the same investigation ; of 
one Department not knowing what another has done or 
is doing ; and of one Department not being able to take 
an obviously desirable step because it would infringe the 
prerogative of another. These matters do not usually 
become public, but we have a striking illustration of the 
want of coordination in the annual returns and statistics 
published by the different offices. 

Statistics relating to Public Health are of great im- 
portance. They afford the only scientific means of deter- 
mining the extent and distribution of disease either in 
classes of persons or geographical areas ; they furnish a 
test of the effects of legislation and administrative orders ; 
and they are, or should be, the basis of new Public Health 
legislation. Without statistical knowledge of the preval- 
ence and causation of industrial diseases and accidents 
in factories, mines, and railways ; of sickness in special 
areas; and of invalidity — efforts to improve conditions 
are based upon little more than guesswork. 

The value of different sets of statistics is very greatly 
increased when they are in a form which renders them 
comparable one with another ; and for this purpose, 
speaking generally, it is necessary that they should apply 
to the same geographical units or units of population and 
the same period of time, divide the classes of persons into 
the same age-periods, employ the same basis of classifica- 
tion of diseases and causes of death, and use scientific terms 



with a constant meaning throughout. But when we turn 
to the Public Health statistics issued by the Govern- 
ment Departments we find the most extraordinary want of 
coordination among them, which often effectually prevents 
them from being used together, and seriously reduces their 
value both individually and collectively. There are at 
least ten different reports which bear upon Public Health 
issued annually by the Home Office, the Registrar- General, 
the Local Government Board, the Board of Education, and 
the Board of Trade, but scarcely any two of them (even 
when issued by the same office) agree in their geographical 
units, or periods of the return, or age-periods, or system 
of classification and nomenclature. There are separate 
Registrar- Generals for Scotland and Ireland, and each 
adopts a form of classification differing in important 
respects from the English system. Some statistics are for 
the United Kingdom only, returns for the separate countries 
not being distinguished ; some are for England, Scotland 
and Wales as a whole ; some for England and Wales, and 
some for England excluding Wales. Uniformity is not 
even observed in the boundaries of the countries, Mon- 
mouthshire, for example, being placed in Wales by the 
Registrar- General and in England by the Home Office. 
The Local Government Board and the Board of Education 
begin their year in April, most of the other offices begin in 
January, but the report on the Working of the Boiler 
Explosions Act begins in July. Some reports tabulate 
deaths registered during the year, others the deaths which 
actually occurred during the year. 1 Systems of nomen- 
clature vary, and even such words as ' violence,' ' neglect,' 
' suffocation,' and ' abortion ' have different interpreta- 
tions placed upon them by different Departments. 

The writer has elsewhere brought forward numerous 
instances of the confusion and difficulties which result 

1 A good instance of the confusion which results from this particular want of 
uniformity is afforded by the returns relating to deaths in coal mines for the year 
1911. According to the Home Office report there were in that year 1050 deaths 
in English and Welsh coalfields ; according to the Registrar-General the number 
was 1364. The difference is almost entirely accounted for by 342 deaths which 
occurred in the Pretoria mine disaster on December 21, 1910, but were not registered 
till January, thus appearing in the Home Office statistics for 1910 and in the 
Registrar-General's volume for 1911. 


from this want of uniformity, and the way in which they 
impede investigation. 1 Deaths from infectious diseases 
are tabulated in one volume, the Registrar- General's 
report, but cases of sickness from these diseases are con- 
tained in another, issued by the Local Government Board ; 
and if we attempt to use these volumes together, we find 
that the Registrar- General classifies his deaths according 
to aggregates of Administrative Counties, County Boroughs, 
Rural Districts, etc., in England and Wales, while the 
Local Government Board classifies the cases in similar 
aggregates for England and for Wales separately. Hence 
the two returns are not comparable except as regards 
England and Wales as a whole, and London, though these 
two offices are supposed to be ' united,' and are under the 
same Minister of the Crown. Remarkable discrepancies 
are revealed by comparison of reports dealing with the 
same deaths, the Registrar-General, for example, recording 
36 deaths from ' alcoholism ' in Liverpool in 1912, while 
the Home Office tabulates 113 inquest verdicts of ' death 
from excessive drinking.' Three Departments, the Local 
Government Board, the Registrar-General, and the Home 
Office, tabulate deaths from starvation, cold, exposure, etc., 
but their totals and geographical distribution of the deaths 
differ widely from each other, and a very simple analysis 
of the Local Government Board report will show that it is 
seriously incomplete. 

Since we have no central statistical office, each Depart- 
ment decides for itself what matters shall be the subject of 
statistical analysis, and how far that analysis shall be 
carried, with the result that remarkable disproportion 
exists between the amount of attention and space given 
to different matters, some being analysed minutely, and 
others of equally great or greater importance being 
neglected. We can learn from the Board of Trade the 
precise number of signal-box lads who suffered from sprain, 
of railway porters who received cuts or lacerations, and of 
engine-drivers who were burnt or scalded. On the other 
hand, the Poor Larw branch of the Local Government 
Board issues no medical report ; and, except for a few 

1 Op. cit. 


details connected with maternity, we have no statistical 
information whatever relating to the great number of 
patients in Poor Law infirmaries ; though the Board 
requires medical officers of these institutions to keep 
proper records. As far back as 1904 the Inter-Depart- 
mental Committee on Physical Deterioration made the 
following recommendation : — 

It appears to the Committee in the highest degree desirable 
that a Register of Sickness not confined to infectious diseases should 
be established and maintained. For this purpose the official 
returns of Poor Law Medical Officers could, with very little trouble 
and expense, be modified so as to secure a record of all diseases 
treated by them. And, further, it ought not to be difficult to 
procure the co-operation of hospitals and other charitable institu- 
tions throughout the country, so as to utilise for the same purpose 
the records of sickness kept by such institutions. 

The Local Government Board however took no action 
in regard to Poor Law medical officers, and it was nobody's 
business to secure co-operation of the hospitals. Had 
the recommendation been acted upon, it seems probable 
that useful information would have been available for the 
actuaries when estimating for the Insurance Act. The 
statistics would not have given a sickness rate in a working 
population, but they would at least have shown that sick- 
ness is greater among women than among men, that 
married women suffer more illness than single women, and 
that pregnancy may be a cause of sickness. 

The Annual Reports of the Registrar-General for 
England and Wales are models of clearness and scientific 
accuracy, and are probably the best of the kind issued by 
any Government in the world. A central statistical 
Department for Public Health purposes is urgently needed, 
and we could not do better than make the Registrar- 
General's Office the nucleus of this Department, not only 
for England and Wales, but for the United Kingdom. 
The report of the Registrar-General for Ireland is also 
good, but in some respects the statistics need standard- 
ising and coordinating in order to render them comparable 
with those of England and Wales. Of the report of the 
Registrar- General for Scotland, Professor Karl Pearson 


said some years ago : " The Scottish statistics are very 
" bad. Scotland has done with her relatively small means 
" such splendid scientific work, that I hope she will pardon 
" me when I say that the data provided by her Registrar- 
" General rank almost at the bottom of European 
" statistics." 1 This criticism is still deserved to-day, for the 
statistical tables seem almost designed to give the minimum 
of information with the maximum of inconvenience. 

The Discouragement of the Present System 

The wasteful, cumbersome, and dilatory procedure of 
Public Health administration in this country is demoralis- 
ing to the official and discouraging to the social reformer. 
The official who comes newly into a scheme which has 
gradually grown up through long ages, finds himself bound 
by Acts of Parliament, legal decisions, regulations made 
by his predecessors, customs and rights. By himself he 
can do little to bring order into the chaos, and his efforts 
at reform will be met by snubs from those who have 
become bond-servants of tradition. Soon he also learns 
that ease and advancement are to be attained by adherence 
to established routine. Social reformers find it difficult 
to fix responsibility : their representations and proposals 
go from Committee to Council, from Council to Board, and 
back to them without effect ; they see their efforts defeated 
again and again, and the abuses they would check, flourish- 
ing year after year. The futility of agitation is realised, 
zeal in the public service is destroyed, and ultimately 
effort is abandoned. All the time knowledge is being 
wasted, and many of the gifts medicine could bring to the 
nation are lost. Sir Clifford Allbutt has well described the 
effects of this confusion in the following words : — 

" Medicine, as a function of the State, is still working 
as it were with her left hand. Her scattered official 
members have no unity ; working everywhere piecemeal 
she has no coordination, no integrated self -conscious- 
ness. With no fixed apparatus for concerted action, energy 

1 Tuberculosis Heredity and Environment, 1912. 


is wasted in overlap, in jostling, in divided purposes, 
and in anomalies. Although her influence is penetrating 
into almost every function of society, and directly and 
indirectly she is spending a great revenue, yet she passes 
through the councils of the nation veiled and irresponsible. 
The new ideas which are stirring society are largely medical, 
yet society does not know where, in the back staircases 
or garrets of the Local Government Board, of the Home 
Office, of the Colonial Office, of the Education Office, of 
the Board of Trade, of the Post Office, of the Registrar- 
General's Department, of the Lunacy Commission, and 
so forth, each bee buzzing in its own little cage, medicine 
is to be found ; nor how this new solvent and all-pervading 
influence is to be brought to the book of revenue, or to the 
bar of public opinion and responsibility." x 

1 Hospitals, Medical Science and Public Health, 1908. 



The lack of scientific criticism of Public Health measures — The need for 
a Ministry of Public Health — Royal Commissions and Public Health 
research — Administrative Offices and Public Health research — The 
Office of the Registrar- General as the Ministry of Public Health — The 
proposal to form a Ministry by uniting the present administrative 
Departments — The personnel of a Ministry of Health. 

The Lack of Scientific Criticism of Public Health 


We have now surveyed the causes responsible for the 
failure to make the best use of medical and scientific know- 
ledge in the interests of the State, and consequently for a 
low standard of Public Health, and we find that they fall 
broadly into three groups, viz. (1) vested interests — mainly 
those attaching to land ; (2) complexity of administration ; 
and (3) mistakes and ignorance of legislators and adminis- 
trators. The first we have already examined ; ways and 
means of overcoming the second and third have now to be 

Throughout almost the whole range of Public Health 
activity we find instances of waste and inefficiency which 
have resulted from sheer lack of knowledge among those 
responsible either for enactment or administration of 
Public Health measures. Preventive medicine is a pro- 
found science, but no expert knowledge seems to be thought 
necessary in those who endeavour to apply its teachings 
to society. When proposals for any new step are made, 
the views of the amateur appear to be regarded as of equal 
weight with those of the lifelong student of Public Health ; 
vague generalities masquerade as scientific deductions ; 



and conclusions put forward by scientific men with reserva- 
tion, and intended only to hold good under certain condi- 
tions, become established truths of universal application. 
We have examined many instances of this process. 
Medicine taught that sanatorium treatment is sometimes 
beneficial in selected cases of tuberculosis ; but politicians 
were responsible for magnifying this into a sweeping general- 
isation, disregarding the truth that tuberculosis is the out- 
come of environment, ignoring the lessons of Germany, and 
thrusting upon the country a costly scheme of treatment 
now shown to be of little avail to cure or prevent tubercu- 
losis among the working classes. Science did not establish 
a system of medical treatment of children which begins at 
an age when already great harm has been done, and 
endeavours to detect ' incipient ' maladies by an examina- 
tion every two or three years ; and science does not 
countenance the view that small weekly payments during 
sickness will compensate for a vicious environment ; nor 
that men and women suffer equally from sickness ; nor that 
maternal ignorance is the great cause of infant mortality ; 
nor that half the total still-births are due to syphilis ; 
nor that tuberculosis is a seriously infectious disease. 
Scientific investigators eagerly demand more knowledge 
of the distribution and causation of disease ; but they 
were not responsible for the folly of the medical record 
cards, and the recording of everything from a cut finger 
to cancer as a basis for scientific monographs. It was 
hasty assumption which gave us a panel service without 
the need for hospital accommodation ever having been 
investigated ; attached so overwhelming a value to treat- 
ment by drugs ; and produced a provision intended to 
improve conditions, based upon sickness rates which cannot 
be obtained. It is ignorance which claims all decline in the 
death-rate as due to sanitary effort ; and ignorance which 
every year leads to more than a thousand mothers being 
wrongfully told that they have overlain and killed their 
babies. Unsound views initiated in high places spread to 
the masses, among whom it may be years before they can 
be eradicated ; while in the accumulation of errors and un- 
workable measures the fundamental causes of sickness 


become obscured, and costly palliatives one after another 
are adopted. Wherever effort to improve Public Health 
has failed, it has not been the fault of medical science, 
but of legislators and administrators who have misunder- 
stood that science, or have failed to appreciate the diffi- 
culties and conditions under which they proposed to apply 
its teachings. 

Under the present system a Public Health Bill may 
pass through the legislature without receiving any expert 
criticism during its whole course. It may be drafted 
in an administrative Department by non-medical civil 
servants, or, if a medical officer to the Department is 
consulted, his views may be overruled by lay authority 
without the public becoming aware of the fact. It may 
be introduced by a Minister who has no special knowledge 
of the subject, and who has not obtained expert opinion 
or consulted learned Societies dealing with its problems. 
The Bill passes through a House of Commons in which 
there is only a handful of medical men, most of whom have 
abandoned medicine for other professions ; and finally 
when it becomes an Act, its administration is placed in 
the hands of a Department in which medicine is kept in 
a strictly subordinate position. We may contrast the 
representation of the medical profession in Parliament 
with that of the legal profession, which contributes one 
quarter of the members of the House of Commons, as well 
as numerous members of the Government ; and we may 
also compare it with the conditions in France, where in 
the legislative body at a recent date, 59 Deputies, 37 
Senators, and 2 Ministers of State were all members of 
the medical profession. 

The Need for a Ministry of Public Health 

The first great step, then, in reorganisation of Public 
Health affairs is the creation of a central investigating 
authority, a Ministry of Public Health, which shall examine 
generally all conditions militating against health, and shall 
advise upon all proposals intended to cure or prevent 
disease. The Ministry would examine all Government 


Bills relating to Public Health, study the conditions under 
which they are to operate, and estimate as far as possible 
their probable effects. It should have the right to in- 
stitute inquiries on its own initiative into conditions 
affecting health in any class or locality ; it should receive 
all scientific and medical reports from other Government 
Offices, Local Authorities, Medical Officers of Health, Poor 
Law Medical Officers, School Doctors, Factory Inspectors, 
etc. ; and it should have power to prescribe the forms in 
which statistics are to be compiled, and returns made by 
every Public Health authority or officer, central or local, 
throughout the country, in order that it may become a 
central Public Health Statistical Office. The Department 
would be a great repository of knowledge, and could act 
in a consultative or advisory capacity to all authorities 
engaged in Public Health administration. 

It is important to notice that the type of research 
which would be undertaken by the Ministry is not so much 
that which depends upon pure science, as that which relates 
to the sociological side of medicine, that is the applicability 
of scientific discoveries to Society. Purely scientific re- 
search into what has been termed the ' test-tube ' side of 
medicine is now fairly well provided for by the Kesearch 
Committee, the grants disbursed by the Local Government 
Board, and assistance provided by the Cancer Research 
Fund, Universities, and learned Societies. These bodies 
however are not constituted adequately to undertake 
sociological medical research, since they have no power to 
prescribe returns and statistics, and to coordinate different 
authorities, and they do not possess the staffs necessary to 
conduct the great and laborious investigations required. 
Sociological research however equally demands pro- 
found knowledge of hygiene and independence of judg- 
ment in the investigator. To secure these, the Ministry 
must be staffed by persons of the highest scientific 
eminence, and it must be practically free from direct 
responsibility for administration. 

Before discussing further proposals for reorganising 
the Public Health services, it may be useful to examine 
two directions in which partial compensation exists for the 


absence of an investigating authority, viz. Royal Com- 
missions on Public Health questions, and investigations 
by Government Departments. By noting the disadvan- 
tages which attach to those methods we shall learn further 
lessons in the need for an independent research authority. 

Royal Commissions and Public Health Research 

The practice of submitting some Public Health questions 
to Royal Commissions, Departmental Committees, or 
similar bodies, is itself an indication of the deficiency in 
expert knowledge in Parliament ; but it does not meet the 
want, for not all questions may be so submitted, and 
Bills of great importance may be introduced without any 
previous investigation having been made. Royal Com- 
missions vary widely both as regards the functions which 
are assigned to them, and as regards the thoroughness of 
their investigations and the value of their reports. Some 
— mainly those appointed primarily to conduct a piece of 
scientific research, and staffed by scientific men — have 
done work of the highest importance. Such were the 
Royal Commission on Human and Bovine Tuberculosis, 
and the Departmental Committee on Lighting in Factories 
and Workshops. The report of the latter, though not of 
general interest, embodies research of the most highly 
scientific, painstaking, and detailed character, and if all 
our Public Health proposals had been submitted to so 
excellent and thorough an investigation we should have 
been saved many a grievous mistake. On the other hand, 
some Royal Commissions are appointed not so much to 
conduct investigations as to give effect to certain widely- 
held, preconceived views ; and their members then usually 
consist of those who hold those views most strongly, those 
who might be expected to oppose them, and representatives 
of persons or interests likely to be affected by the proposals, 
with the result that the main function of the Commissioners 
is to arrive at a compromise between conflicting opinions 
as to what can or ought to be done. Such a Commission 
may be both useful and necessary, but it is not constituted 


to conduct a scientific inquiry, and it cannot be regarded 
as replacing that inquiry. An instance of this kind was 
the Eoyal Commission on Venereal Diseases, which consisted 
of eminent doctors some of whom held strong views on 
the subject before their appointment, representatives of 
religious organisations, Government officials, and persons 
specially interested in women's welfare. The proposals 
of the Commission were therefore highly useful as repre- 
senting the views of a very diverse body of persons as to 
the measures which can be applied to the community. 
But their report cannot be regarded as a scientific docu- 
ment. It makes scarcely any increase in our scientific 
knowledge of these diseases, it contains conclusions founded 
on the scantiest of evidence, and statements which 
appear to the writer contrary to the evidence given by 

Another objection to Royal Commissions is the slow- 
ness with which most of them work. The Royal Com- 
mission on Sewage Disposal was appointed in 1898, but 
did not present its final report until 1915. The Depart- 
mental Committee on the Use of Lead in the Painting of 
Buildings, appointed in 1911, took three years over its 
investigations and preparing its report, but only met on 
forty-nine days during that period. These delays are 
mainly due to the fact that Royal Commissions are 
generally staffed by men busily engaged in other occupa- 
tions who can devote only a limited amount of time to the 
purposes of the inquiry. 

When a Commission has issued its report it is dis- 
banded, and no authority exists which can continue its 
labours, keep its statistics up to date, and maintain interest 
in its proposals. Thus if action is not promptly taken on 
the report, often the whole matter is dropped, and the 
labour of the Commission is largely wasted. The history 
of Public Health effort is beset with instances where this 
has happened. It is notorious, for example, that the present 
system of registering deaths is highly unsatisfactory and 
even dangerous ; and amendment of the law was urged by 
the Select Committee on Registration and Certification of 
Death as long ago as 1893, and at intervals subsequently 


by various public bodies including the London County 
Council and the Medico-Legal Society, but no action has 
ever been taken. State action in regard to venereal disease 
affords another instance. In 1904 the Inter-Departmental 
Committee on Physical Deterioration strongly advised an 
investigation into the prevalence of venereal disease, but 
it was ten years before the Local Government Board, 
stimulated by the International Medical Congress, made 
any inquiry, or took steps leading to the appointment of 
the recent Royal Commission. The central investigating 
body here suggested would in effect be a standing Royal 
Commission on all Public Health questions, and would 
not allow proposals to be dropped until they had been 
considered by Parliament. 

Administrative Offices and Public Health 


The administrative Departments have also at times 
conducted investigations of great value — those, for 
example, of Dr. Newsholme and his staff on infant mor- 
tality have become classic. But the great disadvantage 
of a Department undertaking research into the matters 
it administers, is the difficulty of getting unbiassed in- 
vestigation ; since the Department is nearly always com- 
mitted to some definite line of policy, and is responsible 
for carrying that policy into effect. The Insurance 
Commissioners, for example, are obviously not the persons 
to approach for an impartial investigation into the value 
of the Insurance Act in improving Public Health ; the 
Board of Education cannot avoid exaggerating the im- 
portance of instruction in hygiene, or attributing larger 
effects to the school medical service than it has produced 
or is likely to produce ; and the Local Government Board 
is not the authority to give us, for example, an unbiassed 
monograph on the necessity of continuing vaccination. 
It is impossible to read the Blue-books and reports issued 
by these authorities without realising that each exaggerates 
its own sphere of usefulness in the Public Health scheme. 
Even in reports in which clearly every effort has been 


made to be scientific we find official bias tends to appear. 1 
Freedom from administration is essential for independence 
of judgment. 

Another result of having several Government Depart- 
ments each investigating conditions in an isolated section 
of the community, is to give us an incomplete picture of 
the state of Public Health as a whole. Much attention for 
example has been focussed upon infant mortality, but few 
observers have directed notice towards the great and pre- 
ventable loss of life which is occurring in the second year of 
life. Some diseases and conditions are kept continually 
before the public eye, while others equally or even more con- 
trollable are relatively neglected ; every one is familiar 
with the evil of tuberculosis, but few have realised the ex- 
tent to which we are ravaged by pneumonia and bronch- 
itis from infancy upwards. And equally we receive an 
incomplete and distorted picture of the causes of disease 
and of the steps necessary to prevent them. Certain 
causes of ill-health are continually emphasised while other 
matters of the greatest importance are never investigated 
at all. The Board of Education would have us believe 
that education is the great path to sound national health ; 
the Local Government Board bids us place our faith in 
sewers ; and the Insurance Commissioners will cure us with 
drugs and doctors ; but none of these authorities, or any 
other Government Department, has ever made a compre- 
hensive investigation into the difference between urban 

1 For example, the recent report of the Local Government Board on Maternal 
Mortality in connection with Child-bearing, attributes the high rate of maternal 
mortality in certain Welsh counties in part to deficiency in the quality of supply 
of midwifery assistance, and continues : " If the excessive mortality from child- 
bearing in Welsh and northern counties is ascribable to a material extent to de- 
ficiency of skilled assistance in child-birth, it might be anticipated that the low 
mortality in the last-mentioned counties [Isle of Wight, Buckinghamshire, West 
Sussex, Oxfordshire, Isle of Ely, Stoke of Peterborough, and Rutland] would be 
associated with an adequate medical and nursing service. The evidence on this 
point is, however, imperfect." But why is this evidence imperfect ? These counties 
are more accessible and easier of investigation than those of Wales. Why are 
figures, which prima facie appear to negative the preceding deduction, dismissed 
in a single sentence, and the report published before the exact conditions in the 
counties to which they relate have been investigated ? In another part of the 
report we find the unscientific statement : " No completely consistent relation- 
ship between excessive mortality from child-bearing and a high degree of employ- 
ment in factories is visible in these tables, though it can scarcely be doubted that a 
close association exists between the two factors." It must not, however, be in- 
ferred from these extracts that the report is not a brilliant piece of research into 
an intricate subject. 


and rural mortality and its causes, or has shown that at 
the bottom of nearly all our Public Health difficulties lies 
the land question. Quite properly they would consider 
that this subject is outside their respective spheres, and 
being so, it is outside the sphere of any office — except, to a 
limited extent, that of the Registrar-General — and thus 
this question, the most important of all which relate to 
Public Health, is never adequately studied. 

The Office of the Registrar-General as the 
Ministry of Public Health 

There is one Government Department which is admir- 
ably adapted to be transformed into a Ministry of Public 
Health of the type suggested, and that is the office of the 
Registrar- General. This office is already almost entirely 
in the nature of a research Department ; it has no admin- 
istrative functions except those necessary for its own 
special purposes ; and it produces every year the most 
valuable and highly scientific report on Public Health 
which we possess. The Annual Reports of the Registrar- 
General are conspicuously free from bias ; they serve as 
the basis of all accurate knowledge relating to mortality ; 
they are continually used and quoted by the medical 
officers of other Government Departments who indeed 
would be almost powerless without them ; and their cold 
hard facts give us a true picture of what is occurring, 
without which we should be still more led astray by the 
eulogistic utterances of other Departments which are their 
own judges of their work. The Registrar- General com- 
piles the statistics of births and marriages ; but the great 
bulk of his report is devoted to an analysis of the causes 
and distribution of deaths. What is here proposed is that 
the Registrar-General should do for sickness and disease 
among all classes, infants, children, mothers, insured and 
non-insured persons, paupers, factory operatives, etc., 
what he is doing for mortality ; and that for this purpose 
the whole of the medical statistical work of the Local 
Government Board, the Board of Education, the Home 
Office, and the Insurance Commission should be handed 


over to him with the staffs specially concerned with that 

The Proposal to form a Ministry by Uniting 
the present administrative departments 

It will be objected that the scheme outlined above still 
leaves a number of isolated medical Departments working 
independently, for it is to prevent this that the proposal 
to form a Ministry of Public Health by uniting the present 
offices finds so much favour. But attractive though this 
proposal may seem at first, careful consideration will show 
that there are strong reasons against it. In the first place, 
the medical administrative duties of some of these offices 
are so closely connected with their general spheres of work 
that to separate them would be highly inconvenient. It 
is obvious, for example, that the Board of Education must 
administer the school medical service, for it would be 
extremely confusing for another Department to frame 
regulations concerning grants, visits of school doctors, 
duties of teachers in connection with medical inspection, 
and other matters which demand familiarity with the 
distribution of the schools, the size of classes, times of 
holidays, etc. Similarly the Home Office, which is 
responsible for the general administration of the Factory 
Acts, must control the routine work of the medical 
inspectors who assist in carrying out those Acts. On 
the other hand, the purely scientific and research work 
of both the Board of Education and the Home Office 
could quite fitly be transferred to the Ministry of Public 

The fact is, that it is not so much uniting as coordinat- 
ing which these bodies need, and it is mainly in the scientific 
and statistical work that coordination is required. More- 
over, any union would probably be more in name than in 
fact. We could take out the medical staffs of the Local 
Government Board, the Board of Education, Home Office, 
Insurance Commission, etc., set them down in a building 
in Whitehall, and call them a Ministry of Health ; but the 
result would almost certainly be jealousy and confusion, 


ending in the establishment of a number of separate 
branches, which, though under one roof, would remain as 
much uncoordinated and distinct as they are at present — 
repeating what happened when the Registrar-General, the 
Poor Law Board, and the Local Government Board were 

Finally the great disadvantage would remain that a 
Ministry of Health created by uniting the present medical 
Departments, would still be its own critic and judge. At 
present an administrative Department includes or omits 
just what it pleases in its annual report, prepares the 
answers to Parliamentary questions impugning its ad- 
ministration, and, when publicly attacked, takes refuge 
in the unwritten law — excellent for the Department, but 
prejudicial to the public — that a Government office shall 
never reply to or defend itself against attacks, except 
through the Minister responsible for the office to Parlia- 
ment. In return the actions of the Minister must be 
supported. Thus a kind of confederacy grows up which 
necessarily brings the Department under political influences. 
The officials come to regard their first duty as owed to their 
political chief instead of to the public, and the Department 
must always be made to cut a good figure in Parliament. 
Eulogistic statements and statistics are drafted in the 
office for the Minister to present to Parliament, and if an 
Act does not appear to be working satisfactorily, the 
Department provides the Minister with ingenious answers 
to questions, statements of the extent of its operations, and 
statistics of the number of persons it claims to have 
benefited. The investigations and returns of a Ministry 
of Health would give us more reliable information, and 
would indicate what measures had been beneficial and 
what further efforts are required. 

But while on the whole the principal Departments 
must be left to administer their special services, there is 
undoubtedly room for coordination and re-arrangement 
among them. Administration would be much simplified 
by decentralising many services, and in the next chapter 
proposals will be made for increasing the powers of local 
authorities, particularly in the direction of allowing them 


to establish local medical services in accordance with the 
needs of the locality. If this principle were adopted, many 
of the duties at present discharged by central authorities 
would be transferred to local bodies. It will be proposed 
that medical and sanatorium benefit should be taken out 
of the Insurance Act, and merged into local medical services 
no longer applying exclusively to insured persons. The 
Insurance Commission would then remain simply a 
financial office responsible for the central administration 
of sickness and maternity benefit as forms of assistance, 
and would have no relation to Public Health. Similarly, 
the medical side of the Poor Law might be absorbed by 
the local medical service, and the medical functions of the 
Poor Law branch of the Local Government Board would 
then disappear. The overlapping of the Board of Educa- 
tion and the Local Government Board in the matter of 
maternal and infant welfare might come to an end, and as 
there is no reason why these duties should be performed 
by the Board of Education, they should be transferred to 
the Local Government Board. The duty of compiling 
the annual statistics relating to coroners' inquests should 
be transferred to the Ministry of Health from the Home 
Office ; for the latter has left them practically unrevised, 
and in an almost useless state for nearly fifty years. The 
grant made to the Local Government Board for research 
should be transferred to the Ministry, and the Research 
Committee should form part of the new office. The 
Ministry of Health should take the place at present 
occupied by the Privy Council in relation to the Central 
Midwives Board and the General Medical Council, leaving 
these authorities otherwise unchanged, though it might 
take over from the General Medical Council the duty of 
issuing the British Pharmacopoeia which is a purely 
scientific matter. The duty of the Pharmaceutical Society 
to advise on the scheduling of poisons might also be trans- 
ferred to the Ministry. 

The medical duties of the War Office and the Admiralty 
must remain entirely distinct ; and the functions of the 
Colonial Office in the investigation of tropical diseases are 
also so sharply delimited that there would be no need to 


interfere with them, though the Ministry of Health might 
be authorised to assist in the establishment of schools and 
laboratories for this purpose. 

There are certain other matters which, though they 
involve administrative action, are almost entirely of a 
scientific character, and are therefore appropriate to be 
transferred to the Ministry. Such are the determination 
of what infectious and industrial diseases shall be notified 
under the Infectious Diseases Act and the Factory Acts ; 
the prescribing of standards of purity of milk, butter, and 
other foods, and the issue of regulations for the purpose of 
detecting and preventing adulteration. If the recom- 
mendation of the Committee on Patent Medicines be 
adopted, the control of advertisements of these prepara- 
tions should also be assigned to the Ministry. 

The preceding paragraphs do not purport to contain 
more than the barest outline of a scheme for reorganising 
the Public Health Departments. The suggestions are 
intended to make clear the general principle proposed, viz. 
the establishment of a Ministry of Health, limited in its 
executive powers, but investigating and recording in every 
direction ; and coordinated with it, administrative Depart- 
ments directly responsible for administering Public Health 
measures which demand executive action. But while the 
principle of division is clear the details will require pro- 
longed consideration and very careful adjustment. Prob- 
ably the best plan would be to appoint the Ministry first 
on the lines suggested, and authorise it to inquire into the 
whole system of Public Health administration and recom- 
mend what further changes are desirable. Any other 
course would lead to serious delay in a matter which is of 
the greatest urgency. Suppose for example it is decided 
to form a Ministry on the lines usually proposed of uniting 
the present Departments. The Bill necessary would be 
gigantic in its scope ; and would involve many difficult 
questions, and affect many interests. It could not be 
satisfactorily considered if introduced before the termina- 
tion of the War, and it would probably be delayed until a 
new Parliament had been elected, and even then deferred 
until various after-war problems had been dealt with. If 


the question were referred to a Royal Commission further 
delay would occur. 

On the other hand it would be a comparatively simple 
matter to create the Ministry side by side with the present 
Departments. We should at once meet the greatest 
necessity in our present system, that of an investigating 
authority ; and we could add other duties to the Ministry 
one by one, thus effecting the change with the minimum 
of inconvenience. 

The Personnel of a Ministry of Health 

In order that it may properly discharge the functions 
suggested, the permanent staff of the Ministry of Health 
must consist almost exclusively of medical and scientific 
men. It must include those who have devoted themselves 
to the purely scientific aspects of medicine and hygiene ; 
those who are authorities in special branches, bacteriology, 
pharmacology, food analysis, hospital construction and 
equipment, sanitary engineering, water-supply, industrial 
diseases, statistics, etc. ; and those who have had personal 
experience among the poor as Medical Officers of Health, 
Poor Law Medical Officers, school doctors, and practi- 
tioners, and who know the practical difficulties which 
have to be overcome in applying the results of scientific 
medicine to human beings under the worst possible 

This proposal involves a break with the traditional 
belief that lay civil servants can fitly undertake the ad- 
ministration of medical and Public Health affairs. The 
view that medical men cannot be trusted to exercise more 
than very limited authority, and that they are present in 
a Government office mainly in an advisory capacity 
though they need not be consulted nor their advice taken, 
strongly characterised the earlier administration of the 
Public Health services ; and, though modified, exists to 
this day in the Civil Service to a degree only known to 
those who have had personal experience in a Government 
Office. Writing of the old Poor Law Board, which exercised 


numerous medical functions from 1847 to 1871, Sir John 
Simon said : — 

Perfunctoriness had characterised its work in matters of medical 
responsibility. The root of the fault, giving rise to much which 
had gone wrong in the medical relations of the Office, was, that the 
Board had relied very unduly on the sufficiency of non-medical 
officers in those relations. The original theory seems to have been 
that on any extraordinary occasion extraordinary assistance could 
be obtained ; but that for the ordinary medical business of the 
Board, the common sense of secretaries, assistant secretaries and 
secretarial inspectors did not require to be helped by doctors. 

And writing in 1890 of the earlier years of the Local 
Government Board he said : — 

They did not entrust to the Medical Department any systematic 
share in the supervision. The essentially supervisional arrange- 
ments were to be non-medical ; and except as to the superintendence 
of vaccination (which was let continue much as it had previously 
been) the Medical Department was only to have unsystematic 
functions. In cases where the President or a Secretary or Assistant- 
Secretary might think reference to the Department necessary the 
individual reference would be made ; and where, on motion from 
the Medical Department or otherwise, he might think medical 
inspection necessary, he would specially order the inspection ; but 
these unsystematised inspections could not extend to more than 
comparatively few localities in a year, for the medical staff was not 
allowed the enlargement which had been hoped for a provision for 
larger usefulness. In general, the business of the Public Health 
seems to have been understood as not requiring any other system 
of supervision than the non-medical officers could supply. 

At the present day the Chief Medical Officers of some 
Departments have considerable liberty of action though they 
are always subordinate to lay authority. But this is not 
universal. Under other circumstances the Chief Medical 
Officer of a Government Office, though highly salaried and 
brilliantly qualified, may be kept in a strictly subordinate 
position devoid of influence or dignity. He may not write 
an official letter, he has no voice in the appointment of his 
junior staff, he may or may not be consulted by his ad- 
ministering authority, and, if consulted, his opinion on a 
purely technical point may be disregarded. Some of the 
most elementary mistakes in recent Public Health adminis- 
tration have resulted from such conditions. 


The distrust of the medical administrator in the Civil 
Service appears to arise from fear that he may make a 
mistake in some legal point, or may fail to carry out his 
duties in a strictly official manner. Hence practically only 
lawyers and those who have had a Civil Service training 
may be permitted to handle the administrative machine. 
Even the Chairman of the purely scientific Medical 
Research Committee is a member of the legal profession. 
It is not realised that a mistake in medicine by a legal 
administrator may be infinitely more disastrous to the 
community than a mistake in law by a medical adminis- 
trator. The present theory of official control leads to an 
aggrandisement of the means at the expense of the end. 
The fact that the ultimate aim of the whole machinery, 
authorities, committees, experts, Acts, and regulations, 
is the improvement of Public Health tends to be lost sight 
of ; and the working of the machine in strict accordance 
with the letter of the law, whether beneficial or not, is 
regarded as the great object to be achieved. 

But the training of neither the lawyer nor the civil 
servant fits them to deal with the problems of Public 
Health. Few of them have had personal experience of 
the lives and conditions of the poor when struggling against 
sickness ; the things they deal with are not real to them, 
and in consequence they lack the sense of responsibility 
which knowledge of the way their actions may affect the 
lives of many thousands of humble folk would bring to 
them. This knowledge is only possessed by one who has 
been through the mill himself, who has heard the " knocker- 
up " at 4 a.m., while he sits waiting for the baby to be 
born in a northern slum tenement from which the father 
and children have been turned out on to the stairs, 
or into the overcrowded room of a kindly neighbour ; 
or has spent hours prescribing for a crowd of ailing panel 
patients, knowing all the time how little real good he can 
do them ; or has served as medical officer to a committee 
or authority which can determine his tenure of office, and 
includes among its members some most interested in 
maintaining the very abuses he seeks to abolish. If civil 
servants had had these experiences it is certain that they 


would give far more consideration to the circulars and 
administrative orders which emanate from Government 
offices. We should not have red tape continually hinder- 
ing the already tardy assistance given to the working 
classes ; decisions arrived at on the most perfunctory 
investigation ; the last items on a Committee's agenda 
hurried through ; medical opinion continually overruled ; 
and vitally important questions indefinitely postponed 
simply because they are difficult to deal with. It was once 
proposed that every Judge of a Criminal Court should 
spend a week of the year in prison; and on the same 
principle it is to be regretted that we cannot compel every 
lay Public Health official to spend a month as a panel 
doctor in a slum district. 

Moreover, the average civil servant has not had the 
scientific training, which would enable him to distinguish 
between sound deductions and unverified generalities ; and 
he has no means of acquainting himself with advances in 
medicine and hygiene. It is the absence of this training 
in the majority of civil servants which makes them so 
timorous of doing anything that involves innovation or 
liberty of action. For every step justification must be found 
in an Act of Parliament or regulation, and the attitude 
towards medical men is expressed in the words of a Secre- 
tary of a Government Office who said to the writer : " The 
medical men we want here are humdrum persons who 
won't be continually proposing new things. We don't 
want clever doctors in the Civil Service." Tradition and 
precedent are their guides, reinforced by the appreciable 
proportion of lawyers in the service ; yet precedent, so 
dear to the lawyer, is the very last principle which should 
govern administration of the ever-changing and ever- 
widening sphere of Public Health. 

The objection may be made to these proposals that 
they tend to place too much power in the hands of doctors. 
The fact must be recognised that, whether justified or not, 
there is among the laity considerable distrust of the 
medical profession ; and the plea would certainly be made 
that, even if the staff are medical men, the supreme head 
of the Department must be a layman, — a principle which 


has been almost invariably observed in the War Office and 
Admiralty. 1 These, however, are executive offices, possess- 
ing powers of compulsion over the acts and lives of citizens, 
and in a democratic country their ultimate control must 
remain in lay hands. But the Ministry of Health here 
proposed is of an entirely different character. It is to be 
an office for research and investigation, and is to have no 
authority, except such as comes from the weight of its 
opinion ; and no power of issuing orders, except such as 
are required for purposes of research and the advancement 
of knowledge. It is therefore much more comparable 
with, let us say, the Geological Survey, and at the head of 
this no one would propose to place other than a geologist. 
But just as the authorities which use the results of the 
Geological Survey, its maps, its knowledge of mines, its 
information regarding water-supply, etc., are under lay 
control, so the administrative Departments which em- 
ployed the knowledge collected by the Ministry of Health 
would remain as at present under lay authority. Whatever 
scheme for a Ministry of Public Health be adopted, it 
must be recognised that if it is to be administrative, it 
must ultimately be subject to lay authority. Nothing 
else is in accord with democratic principles. But in the 
opinion of the writer it is well worth sacrificing all authori- 
tative power in order to obtain the inestimable advantage 
of a scientific, independent, and unbiassed body which 
would be continually investigating the state of Public 
Health and the value of measures designed to improve 
it, thereby reducing to a minimum the costly errors and 
futile efforts which have sometimes attended Public Health 
activity in the past. 

1 Mr. Bernard Shaw has said : " I do not know a single thoughtful and well- 
informed person who does not feel that the tragedy of illness at present is that it 
delivers you helplessly into the hands of a profession which you deeply mistrust." 
— Preface to The Doctor's Dilemma. And Miss Margaret McMillan, voicing un- 
educated opinion, has said : " Yet I think it is impossible to deny that while the 
individual doctor has many friends, the profession is regarded by the public with 
some doubt and even distrust. No one who has been engaged for years in trying 
to bring the doctor into the schools of the land can help knowing that there is a 
strong and deep feeling of misgiving at the thought of extending the power and 
influence of the medical profession." 



The responsibility of local authorities — The decline of democratic control 
in Public Health — Local needs and local control — Local administration 
and the cost of sickness — A single local health authority or ' Local 
Health Council ' — Should the Health Council be the present Local 
Authority or a new body ? — Coordination of the Local Health Council 
and the Local Authority — A suggestion for financial arrangements — 
The question of a local medical service — The position of the voluntary 
hospitals — Conclusion. 

The Responsibility of Local Authorities 

Local administration in Public Health is, or should be, 
governed by very different principles from those observed 
in central administration. Local authorities — including 
in the term not only Local Sanitary Authorities, but 
Insurance Committees, Boards of Guardians, etc. — are 
the actual executive bodies, since they have to carry into 
effect all orders and decisions, whether made by them- 
selves or by higher administrative authority, or embodied 
in Acts of Parliament. Democratic principles demand 
therefore that local authorities should have a large share 
in the making of these decisions, and in determining the 
means by which they are to be given effect. Though a 
central investigating body composed of scientific men 
must necessarily have severely limited powers, executive 
power must exist somewhere, and in the scheme to be 
outlined in this chapter it is proposed that local authorities 
— or rather one local authority formed by combining the 
various local Public Health authorities — shall be given the 
largest share in the control of Public Health affairs for 
local purposes. 



The Decline of Democratic Control in 
Public Health 

This is a democratic country, nevertheless the system 
of Public Health administration which has grown up is 
rapidly removing the control of the people over many 
matters which intimately affect their lives and welfare. 
We have seen that the Insurance Act was passed without 
any mandate from the country ; this however was done 
by Parliament, and the constitution provides a means of 
reversing it — in theory at all events — if popular disapproba- 
tion is sufficiently great. But there is no means of con- 
trolling the actions of administrative bodies. Parliament 
more and more leaves matters unfinished or undefined in 
Acts of Parliament, and assigns to Government offices the 
duty of giving them shape and form ; with the result that 
some of these offices are now almost legislative authorities, 
issuing orders and regulations of sweeping importance, 
which have not only not received democratic assent, but 
clearly never would have received that assent. It might be 
argued that these orders and regulations relate to matters 
requiring special knowledge which are therefore unsuitable 
for democratic control, and if Departmental administra- 
tion had always been sound, and conducted solely with a 
view to public welfare, we might accept this proposition ; 
but we have only to look again at the state of Public 
Health in this country, and to recall the numerous 
mistakes, muddles, and partiality of C4overnment offices, 
in order to realise that local democratic control would at 
least not have been a greater failure than control by civil 
servants who are in no sense representative. 

It may be noted that even when an Act of Parliament 
purports to give a degree of local autonomy, liberty of 
action may be nullified by the central Departments. Con- 
sider, for example, Section 15 of the Insurance Act which 
begins : " Every Insurance Committee shall for the purpose 
of administering medical benefit make arrangements with 
duly qualified medical practitioners in accordance with 
regulations made by the Insurance Commissioners." An 
ordinary person reading these words would suppose that 


Insurance Committees had some freedom of action in 
regard to medical benefit, and his belief would be 
strengthened by other elaborate provisions of the Act for 
securing that Insurance Committees should be representa- 
tive of insured persons, County Councils, etc. But as a 
matter of fact all arrangements made by Insurance Com- 
mittees must be " approved " by the Insurance Com- 
missioners, and by the simple process of intimating 
beforehand the only arrangements they will approve, the 
Insurance Commissioners obtain at one stroke entire 
control throughout the country. Insurance Committees 
have no voice in determining the rate of remuneration of 
doctors, or the scope of medical benefit, and no power to 
make better arrangements. A glance at the agenda of 
an Insurance Committee will show how trivial are the 
matters in which they are allowed any freedom, and as a 
matter of fact, almost all their duties could have been dis- 
charged by a clerk directly appointed by the Insurance 
Commissioners. The result is that men of public spirit 
and energy do not care to accept positions of so little 
dignity and importance, and local administration suffers. 
This has been well expressed by a recent writer in the 
Hearts of Oak Journal who, commenting on resignations 
of members of the City Council of Exeter from the In- 
surance Committee, said : " We need not examine griev- 
" ances in detail. Every one who has been associated with 
" the management of the Act is cognisant of the struggle 
" that has been waged between local administration and 
" bureaucracy. It is a case of centralisation v. decentral- 
" isation, and the central powers having the purse have 
' w been able to make their will prevail. Insurance Com- 
" mittees are now very little more than conduits, without 
" initiative or authority, and I believe the public men 
" who have just retired from the Exeter Committee feel 
" that they can put their time to better use." 

It is important to bear in mind the extent to which 
local bodies are controlled by higher authority, since this 
is one reason why local administration sometimes appears 
defective, and is blamed unjustly. Those who advocate 
centralisation of Public Health control generally do so on 


the ground that local authorities are inclined to be ' apa- 
thetic,' and that the central Departments must be in a 
position to bring pressure to bear upon them. But we 
cannot rely upon this pressure being exercised even where 
it would be justified ; and for many difficulties and apparent 
neglect, the central Department is often more to blame 
than the local authority. The Local Government Board 
or the Insurance Commissioners, however much they may 
inspect and obtain reports, can never be as fully informed 
of the local conditions and difficulties as those who are 
living on the spot, and if a central authority issues orders 
which are inappropriate, or refuses assent to schemes 
which are sound, the local authority is too often blamed 
for the consequent failure. 

Local Needs and Local Control 

Another reason for giving wide discretionary powers 
to local authorities in Public Health administration is the 
fact that they know better than any central authority 
what are the causes of sickness in the locality, and how 
they may best be prevented ; and decentralisation permits 
of wide elasticity in the measures taken according to local 
needs and exigencies. The conditions and requirements 
of Public Health in different localities — an industrial town, 
an agricultural district, a seaport or a mining area, are 
so diverse that it is simply impossible to deal with them 
by uniform methods ; yet this is what centralisation in- 
volves. We have applied a rigid and uniform panel 
system over the whole country, yet so enormously does 
the demand for medical attendance vary, that while one 
doctor finds his remuneration averages Is. 6d. per attend- 
ance, another receives several pounds for each visit or 
consultation. We have made the Notification of Births 
Act compulsory over the whole country, yet we have seen 
that the distribution of infant mortality is exceedingly 
unequal, and that in a large number of rural districts it 
is probably as low as it is possible to make it by human 
endeavour. Identical conditions of bad housing or over- 
crowding are far more injurious, and demand more radical 


treatment in large urban areas than in country villages ; 
and the incidence of tuberculosis, venereal diseases, in- 
ebriety, etc., vary within such wide limits, and depend so 
much upon local conditions, that they can only be dealt 
with effectively by persons intimately acquainted with the 
circumstances of the locality. The application of uniform 
methods is extravagant and inefficient, and the belief that 
what is good for one district is necessarily good or desirable 
for another, leads to an erroneous method of measuring a 
local authority's activity, which is a further cause of un- 
reasonable complaint against local administration. Critics 
of a Borough Council's work do not estimate its value 
from the local death-rate or incidence of sickness, which 
often they know nothing about, but from the number of 
officials it has appointed, and the number of schemes it 
has devised for doing things, many of which may be un- 
necessary. If a Borough Council has not appointed a 
staff of health visitors, it is certain nowadays to be held 
up to public obloquy, no matter how low the local rate of 
infant mortality may be. Under the scheme here pro- 
posed, the local authority responsible for the case of Public 
Health should have full control over all matters pertaining 
thereto, except those which must obviously be uniform 
over the whole country, such as the methods of preventing 
food adulteration or the notification of industrial diseases ; 
should have power to provide whatever medical services, 
institutions, etc., are necessary in the locality ; and should 
be able to act on its own initiative without having to incur 
the delays necessitated by continually submitting its pro- 
posals to Government Departments. 

Local Administration and Cost of Sickness 

If local authorities are made responsible for the care 
of health and for the provision of medical services and 
institutions for treatment, it almost necessarily follows 
that each locality must bear the cost, or the major part of 
the cost, of these measures. This principle has the great 
advantage that by making each locality pay the cost of 
its own sickness, a strong stimulus is provided towards 


remedying insanitary conditions. Ratepayers and local 
authorities would find that in the long run it was much 
cheaper to clear slums and otherwise establish healthy 
conditions, than to pay for the continued upkeep of 
hospitals, infirmaries, sanatoria, and medical services. 
Moreover, this system is very much fairer in view of the 
unequal incidence of sickness. We have seen how the 
Insurance Act is operating as a tax on rural areas for the 
benefit of industrial towns ; and a large part of Government 
expenditure and Parliamentary grants-in-aid, provided 
out of general taxation for Public Health purposes, such 
as those for the school medical service, Poor Law infir- 
maries, housing schemes, and infant clinics, in the last 
analysis, penalise healthy for the benefit of unhealthy 
districts and industries. Perhaps the most striking 
example is the recent provision for the treatment of 
venereal diseases. Although the report of the Royal 
Commission showed that syphilis is much more prevalent 
in large towns than in rural districts, only 25 per cent of 
the cost is to be raised locally, and 75 per cent is to be 
provided by Government grant, thus making many 
districts where syphilis is almost unknown contribute a 
substantial part of the expenditure, and proportionately 
reducing the incentive to the Local Authorities, where 
the incidence of the disease is high, to take steps to 
prevent it. Nor are grants-in-aid alone involved, for 
healthy localities are also paying an unfair share of the 
cost of central administration and official salaries. 

While the general principle of local payment of cost 
might be observed, it would not necessarily be sound to 
insist on its rigid observance in every case. Very poor 
districts might legitimately receive special assistance, and 
where the action of one authority benefits contiguous areas, 
as in a scheme for water-supply or drainage, the cost would 
need to be apportioned. Moreover, the sickness in a 
particular district may not be entirely its own fault ; the 
sickness in Stepney, for instance, is undoubtedly partly 
due to the fact that it is surrounded by other unhealthy 
districts, but for the purposes indicated, London would 
probably have to be regarded as one unit. These how- 


ever are matters of adjustment which do not affect the 
general principle. 

To summarise then, the chief reasons for increasing 
local authority in Public Health are : (1) to preserve 
democratic control ; (2) to enable local authorities to 
provide exactly what they need ; and (3) to give them a 
direct incentive in reducing local sickness to the minimum. 
The charge that local authorities are apathetic is not estab- 
lished as a general truth. We have already noticed the 
zeal displayed by Bradford and other Borough Councils, and 
an increase in the dignity and power of these authorities 
would attract men of capacity to their service, and stimu- 
late public interest in the problems with which they deal. 

A Single Local Health Authority or ' Local 
Health Council' 

We have seen that in central administration of 
Public Health it is desirable to keep certain Departments 
separate, since their medical duties are so closely related 
to their general spheres of activity ; but in local administra- 
tion the reasons for division of authority no longer hold 
good. A local authority is concerned with a definite 
geographical unit, and a community of persons all subject 
to more or less the same conditions, and it is wasteful and 
inefficient to have a number of uncoordinated bodies, 
Local Sanitary Authorities, Insurance Committees, Boards 
of Guardians, and Education Authorities, each concerned 
with a special section of the community as though it were 
in a water-tight compartment. These should be replaced 
by a single body or ' Local Health Council,' as it 
might be termed. The new authority should be con- 
cerned with the health of all persons within its district ; 
it should be empowered to investigate all the causes 
responsible for preventable disease within its juris- 
diction, and it should provide the medical attendance, 
hospitals, sanatoria, lying-in homes, convalescent homes, 
and other institutions which the particular conditions 
within its area necessitate. If this plan were adopted, 
certain local administrative bodies would disappear, and 


others would remain simply to discharge non-medical 
functions. It has already been suggested that medical 
and sanatorium benefit should be taken out of the Insurance 
Act ; and Insurance Committees could then be abolished, 
the obligation to provide necessary medical attendance 
not only for insured persons, but for their dependents 
being discharged by the Local Health Council, while all 
sanatoria and dispensaries for tuberculosis would pass into 
their possession. The Boards of Guardians would hand 
over to the new authority their duty of providing for the 
sick poor, no longer to be distinguished from other classes 
of the community unable to afford adequate medical 
attendance, and their work in connection with public 
vaccination ; and would transfer their infirmaries and 
similar institutions, and their staffs of indoor and outdoor 
medical officers. Thus the Guardians would remain 
simply as an authority for the relief of destitution. The 
school medical service would be administered by the Local 
Health Council, but only as a part of a larger scheme for 
providing for all children whether at school or not. The 
Medical Officer of Health would be the chief permanent 
medical officer of the Local Health Council, and the 
tuberculosis officers and staff of sanitary inspectors, health 
visitors, etc., would pass under its control ; the local 
registrar of births, deaths, and marriages should be affiliated 
to the Council ; and the Coroner should be required to 
send to the Council reports on all deaths from industrial 
diseases, neglect, starvation, lack of medical attendance, 

Should the Local Health Council be the Peesent 
Local Authoeity oe a New Body ? 

The question remains to be considered whether the 
Local Health Council should be the present Local 
Authority with its powers enlarged, or whether it should 
be an entirely new body to which are transferred the Public 
Health duties of the present Local Authority together with 
those of other authorities. The first system has the merit 
of simplicity, since it would place all local administration 


in the hands of one body. Nevertheless it appears to the 
writer more advantageous to adopt the second, thus giving 
us a Local Health Council in every County and County 
Borough dealing exclusively with Public Health affairs, 
and a Local Authority concerning itself with all other 
spheres of municipal activity. A plan for coordinating 
these two bodies, and for adjusting certain matters wherein 
they might overlap, will be considered later. 

The first reason for advocating an independent Health 
Council is the fact that the present Local Authority may 
be influenced by different and opposite motives, some of 
which may not operate in the interests of Public Health. 
It is the rating authority, and usually a proportion of its 
members have been elected for the express purpose of 
lowering the rates ; while at the same time it is expected 
to undertake schemes for the protection and improvement 
of the Public Health, some of which may be of a costly 
character. Secondly, a Local Authority is usually, and 
quite properly, interested in the commercial prosperity of 
its town or district ; and since local administration has 
tended to pass largely into the hands of the trading and 
business class, the Local Authority may be unduly con- 
cerned in protecting commercial interests to the prejudice 
of Public Health. A scheme for rebuilding or widening 
a main street or establishing an open space is considered 
not only from the point of view of Public Health, but also 
as regards the effect it will have on the general trade of the 
locality and on the interests of the shopkeepers displaced, 
some of whom may actually be members of the Local 
Authority. In a fashionable resort or seaside watering- 
place a fever hospital must not be built here or a sanatorium 
there, lest it may keep visitors from the town ; in an in- 
dustrial district, the interests of the factory, in which large 
numbers of the local people earn their living, and which 
has perhaps ' made ' the town, must not be unduly inter- 
fered with. Nor is concern lacking for even humble 
interests. In many districts costers are permitted to 
crowd narrow thoroughfares with their stalls, and litter 
the road with vegetable refuse, simply because they have 
an ancient prescriptive right to be there. It is not 



suggested that Local Authorities are wrong in taking this 
attitude, having regard to their character and general 
functions, but it is one which clearly must often conflict 
with strict concern for the Public Health. 

As regards the method of appointing a Local Health 
Council, while the principle of democratic control must 
be observed, it would perhaps be better for the Council 
to be nominated by bodies themselves elected rather than 
be directly elected by popular vote. It may be suggested 
that the Local Authority should nominate one-half of the 
members of the Local Health Council, which would in 
effect amount to its transferring its Sanitary Committee 
to the new Authority. One-quarter might be nominated 
by the Boards of Guardians, and the remainder by the 
managers of local hospitals and the Ministry of Health. 
One member might be nominated by the Member of Parlia- 
ment for the locality, a system which would give the Health 
Council a direct connecting link with Parliament, and 
afford ready expression of its opinions in the legislature. 
The advantage of nomination over election lies in the fact 
that it would enable persons to become members of the 
Council who would not care to face popular election, 
such as professional men, writers, and University lecturers. 
A service which had a sphere of scientific investigation and 
a direct concern with all Public Health questions would 
undoubtedly prove attractive to a type which at present 
rather tends to hold aloof from municipal administration. 

In London the question is more complicated. Perhaps 
the best plan would be to enlarge the powers of the Metro- 
politan Asylums Board, making it the general authority in 
London to provide medical services, and leave to the London 
County Council most of its present Public Health duties. 
The London Insurance Committee would disappear. A 
Local Health Council could be created in each of the 
Metropolitan Boroughs, but the division of function 
between it and the enlarged Metropolitan Asylums Board 
would require to be defined. The Boards of Guardians 
would remain only as authorities for the relief of destitution. 


Coordination of the Local Health Council 
and the Local Authority 

In most directions, particularly those of providing local 
medical services, the duties of the Local Health Council 
would be sharply denned, but inconvenient overlapping 
might arise in certain matters which are not exclusively 
concerned with Public Health, such as Town Planning and 
housing schemes, and water-supply. These matters in- 
volve heavy expenditure, interference with vested interests 
and rights, compensation and other legal questions with 
which, apart from their Public Health aspects, the Local 
Health Council would not be best suited to deal. Matters 
of this nature, which concern closely both Authorities, 
might be referred for settlement to a standing Joint Com- 
mittee, one-half appointed by the Local Authority, and 
one-half by the Local Health Council. 

A Suggestion for Financial Arrangements 

It would obviously be highly inconvenient to have two 
authorities raising local funds, and the Local Authority 
must clearly remain as the only local rating authority. 
Moreover, it must have reasonable power to control or 
approve of expenditure by the Local Health Council, for 
if the latter were given carte blanche to spend what it 
liked, its zeal might easily outrun economic discretion. 
The following scheme for securing co-operation may be 
suggested : The Local Health Council should annually 
estimate its expenditure for the forthcoming year, and 
present this estimate to the Local Authority with a full 
statement as to the reasons for the expenditure, the Local 
Authority being entitled to ask for any further information 
it considered necessary. If the Local Authority approved 
the expenditure, it would provide the sum required. If it 
disagreed on any points, these matters should be referred 
in the first instance to the Standing Joint Committee. If 
the Committee were unable to arrive at a settlement 
acceptable to both authorities, then the disputed questions 
should be referred for final decision to the Local Govern - 



ment Board acting in conjunction with the Ministry of 

The Question of a Local Medical Service 

The provision of a complete and adequate medical 
service for the treatment and care of sick persons is one of 
the most difficult questions which the country must face 
in the near future. The service established under the 
Insurance Act has not fulfilled its original intentions, has 
been very costly, and has given rise to widespread dis- 
satisfaction. It is well known that reorganisation of the 
panel service is contemplated, and the proposal to establish 
a national medical service, though not generally approved 
by the doctors, is steadily gaining adherents. In favour 
of a national service it is argued, that while paying the 
doctors good salaries it would be less costly than the 
present system ; that it would enable a better distribution 
of doctors to be made ; that the doctors would no longer 
be competing against each other for patients or be in- 
fluenced by financial considerations ; and that consultants, 
specialists, and institutional treatment could be added to 
the service. The extreme proposals extend to nationalisa- 
tion of the voluntary hospitals. Against a national medical 
service it is urged, mainly by the doctors, that it would 
preclude freedom of choice of doctor by patient, would 
make the doctor a servant of the State thereby limiting 
his freedom of action, and would lessen his personal interest 
in the welfare of his patient. 

It is doubtful however whether those who advocate 
a national medical service have fully realised the immense 
difficulties which stand in their way. Let us for the 
moment fix attention upon that part of the service which 
is concerned with medical practitioners, leaving institu- 
tional and special treatment for later consideration. In 
the first place the service must be open to all but the upper 
and middle classes ; for as soon as we begin to define the 
persons who should be entitled to the service, we find it 
impossible to draw any other line than that which would 
be voluntarily adopted ; and this would entail a much 
greater degree of interference with private practice than 


was effected by the Insurance Act. A service of whole- 
time salaried officers clearly could not be restricted to 
insured persons, for that would lead to one doctor attend- 
ing the father, and another the wife and children, a system 
which would never be satisfactory. If the doctors were 
only part-time, and were allowed to undertake private 
practice as well, other obvious objections would arise in 
many districts. The first enlargement then would be to 
include dependents of insured persons ; but this would 
involve all kinds of difficulties in defining a ' dependent,' 
and it would leave out of the service a large number of 
poor persons who are neither insured nor dependents of 
insured persons. The next proposal accordingly is to take 
in all persons whose income is below a certain limit. But 
apart from the fact that it would be very difficult to obtain 
agreement as to what the limit should be, and that the 
scheme takes no notice of varying claims on income, it is 
almost impossible to determine incomes among the work- 
ing classes ; and in the end we should have to adopt the 
limit taken for revenue purposes, which the doctors would 
almost certainly consider too high. During the con- 
troversy over the Insurance Act the British Medical 
Association urged the fixing of an income limit of £2 per 
week. To observe this it would be necessary to obtain 
returns from millions of the working classes ; to determine 
the annual incomes of wage-earners employed during part 
of the year and unemployed for another part, sometimes 
at one rate and sometimes at another, and perhaps in 
different localities ; to decide questions of allowances for 
tools, insurance, children, etc. ; and to determine the 
position of the wife's income from charing, or the son's 
from selling newspapers. The scheme is so impossible 
that it is difficult to realise how it could ever have been 
seriously put forward. It would be practicable to adopt 
the income tax limit, but even this would entail an immense 
amount of indexing, registering, compiling of doctors' lists, 
etc. The number of income tax payers and their de- 
pendents in England and Wales has been estimated at 
some six millions. 1 Under the scheme, therefore, the State 

1 This was before the recent lowering of the limit of income subject to taxation. 


would have to provide a medical service for some 30,000,000 
persons, and find salaries for the great majority of general 
practitioners in the country. However strongly this 
course may be urged, we may be certain that under circum- 
stances now existing, and likely to exist for a considerable 
time, it will not be adopted. Moreover, for large numbers 
of people in healthy districts a medical service is by no 
means the most pressing need, and even in towns a 
service of general practitioners is not nearly so urgently 
required as an increase of hospital accommodation. 
Finally, we must recognise that rightly or wrongly the great 
bulk of general practitioners are strongly opposed to a 
national medical service, and no one wishes the scenes and 
incidents of 1911 and 1912 to be repeated ; yet without the 
co-operation of the practitioners, a national service is 
almost impossible of achievement. 

But even if it were feasible, the great objection to a 
national medical service remains, viz. that it takes little 
cognisance of differences in local needs and conditions. It 
applies the same principle to Bournemouth and Birmingham, 
to Cumberland and Camberwell. Under these circum- 
stances therefore it is suggested that we should abandon 
the idea of a rigid, centralised medical service, and 
endeavour to establish instead an elastic, local medical 
service under the Local Health Council, which should 
have wide powers to vary the service according to the 
needs of its district. 

The reasons for leaving the form of a medical service 
to local decision are even more numerous than those which 
apply to other branches of Public Health, for in addition 
to variations in the causes and incidence of sickness, it is 
necessary to take into consideration social circumstances 
and geographical conditions. Difficulties which arise in 
Kensington would not occur in Whitechapel. In one 
district the establishment of a complete medical service 
working through clinics would meet with no opposition ; J 

1 It is of interest to note that such a system has been in operation for many 
years at Swindon among the 43,000 employees of the Great Western Railway and 
their families. There is a staff of doctors with graduated salaries, and the town 
is divided into a series of districts, each under the care of one doctor with a central 
dispensary for the whole system. The medical service is good and the arrange- 


in another it would only be necessary to supplement private 
practice by appointing a certain number of salaried medical 
officers in charge of public dispensaries ; in scattered areas 
arrangements could be made with private practitioners to 
attend outlying villages or hamlets ; and in yet others the 
doctor might be guaranteed a minimum income, or pro- 
vided with a motor or a house on the lines followed by the 
Highlands and Islands Board, a development which itself 
shows how local circumstances have compelled a modifica- 
tion of a general scheme. Different systems of payment 
would be available, and would enable the remuneration of 
a doctor to be adjusted broadly to the time and services 
he gives. A capitation fee which yielded Is. 6d. per 
attendance would be recognised as too low, and one from 
which the return is measured in pounds per attendance 
as too high. The arrangements made with the doctors 
might only apply to certain areas, and the doctors could be 
limited as to the number of patients they attended. It 
may be noted that since the fundamental cause of dis- 
satisfaction among the doctors is interference with lucrative 
private practice, the poorer the district and the greater its 
needs the less likely is difficulty to arise. 

The Local Health Council should also be empowered 
to investigate the need for special or hospital treatment in 
its district, and to provide whatever forms of institutional 
treatment are required. Probably in most districts this 
would be found to be the most pressing want, and if 
adequately met, it would often not be necessary to provide 
general practitioners or interfere with private practice at 
all. The Local Health Council would take cognisance 
of voluntary hospitals in the district ; and its endeavour 
would be not to establish its own complete service, but to 
supplement existing services and make good deficiencies, 
providing in one district a hospital, in another a sana- 
torium, in another a convalescent home, while infant 
clinics, children's clinics, lying-in homes, bacteriological 
laboratories, and institutions for the permanently disabled 

ments appear to have been satisfactory to both patients and doctors. Such a 
scheme is only feasible where the area is compact, the persons entitled to the benefit 
of the service are clearly and easily defined, and the bulk of the populacion consists 
of these persons. 


who require medical care should all be within its province 
to establish if necessary. 

Towards the provision of these services the Local 
Health Council would have already entered into possession 
of municipal hospitals and sanatoria, Poor Law infirmaries, 
school clinics, and kindred institutions. Where further 
accommodation was needed, the Health Council should be 
able to build its own hospitals, or make arrangements with 
voluntary hospitals, or combine with adjacent localities 
in the joint use of hospitals. Coordination alone would 
appreciably increase accommodation, for at times Poor 
Law infirmaries have many vacant beds while voluntary 
hospitals in the same town have long waiting lists. There 
are signs of a new era in hospital construction which should 
substantially reduce the cost of building. Open-air treat- 
ment is dow being extended to infectious diseases ; and at 
Cambridge an open-air hospital with 1450 beds has been 
erected for wounded soldiers and has achieved highly 
satisfactory results. Dr. Shipley considers the cost of 
construction of the Cambridge hospital to be only £17 
per bed. 1 

The Position of the Voluntary Hospitals 

These proposals open up an exceedingly wide and 
important question, viz. the relation of the voluntary 
hospitals to the scheme proposed, or to any other scheme 
for reorganisation of the public medical services. National- 
isation or State support of the voluntary hospitals has been 
strongly urged by that school which believes in the advan- 
tage of nationalisation or municipalisation as a general 
principle. But the reasons adduced for applying the 
principle to the voluntary hospitals are not convincing. 
It is stated for one thing that the hospitals are often in- 
adequately supplied with funds, and that they cannot 
therefore increase their accommodation to meet the 
demands made. This is undoubtedly true, but it furnishes 
only an argument for supplementing the voluntary pro- 

1 Furthe- details of this interesting experiment will be found in Dr. Shipley's 
pamphlet, " The Open-Air Treatment of the Wounded." 


vision, and not for State acquisition of the whole system. 
Another reason, which possesses more force, is that the 
care for national sickness should be a national charge, and 
should not be left to the uncertain charity of philanthropic 
persons. To those general arguments are sometimes added 
assertions that the hospitals are extravagant and in some 
cases inadequately staffed. 

But while due consideration must be given to these 
views, the arguments against them appear to the writer 
overwhelming. In the first place most of the larger 
hospitals, though not technically so, are actually 
" national " for all practical purposes, particularly those 
which have accepted a degree of supervision by the great 
hospital funds, to which contributions are made by all 
classes of the community. Most hospitals publish accounts 
of their expenditure ; are governed by a representative 
body of managers ; and are liable to public criticism for 
errors or inefficiency, which is far more likely to be effective 
than if they were institutions of the State. Moreover, 
there is little scope for improved management under State 
control, for the organisation and internal administration 
of the British hospitals has deservedly earned a high 
reputation. When we consider the number, size, and 
variety of the voluntary hospitals, the extent of the funds 
they handle, the number of persons who receive treatment 
from them, the responsibility of their work, and the tact 
and discretion demanded in maintaining harmonious 
relations between patients, doctors, nurses, and sub- 
scribers, it is astonishing how rare are complaints of in- 
efficient treatment, mismanagement, or malversation of 
funds. In a nation not conspicuous for excellence of 
public administration very strong reasons should be shown 
before terminating this system and placing the hospitals 
in the hands of the Civil Service. The medical staffs of 
the voluntary hospitals are almost always selected on the 
grounds of merit, and in the making of appointments there 
is far less nepotism or exercise of improper influences than 
occurs in the Civil Service Departments. 

Another reason is of a practical rather than an ethical 
character. The community should realise that in the 


hospital service at all events they have made an exceedingly 
good bargain with the doctors. It is probably not often 
appreciated that as far as private practice is concerned the 
whole body of consulting physicians, and still more of 
surgeons draw their clientele from a small fraction of the 
community. Harley Street and Wimpole Street derive 
more income from an acre in the west than from a square 
mile in the east of London ; and it is only the voluntary 
hospitals which bring their services to the aid of many 
thousands of poor persons. It is not denied that there 
are indirect advantages in being on a hospital staff, particu- 
larly to the younger men who have yet to make their 
reputations, but we find many eminent physicians and 
surgeons to whom such considerations have long ceased to 
appeal, continuing to visit the hospital year after year on 
their appointed days, and discharging their duties without 
remuneration. In their case, while admitting that the 
work is of interest and the position dignified, undoubtedly 
a sense of duty to the hospital and philanthropy to the 
poorer sections of the community keeps them at their 
post. If the voluntary hospitals were converted into 
State institutions under official control, it is very probable 
that this public-spiritedness would be lessened, and the 
doctors would be justified in asking for remuneration for 
their labours. 

Yet one more point must be mentioned. If the State 
were to take over the hospitals, many charitably-disposed 
persons would consider that the hospitals no longer 
required private support, and would seek other oppor- 
tunities for their benefactions. Thus the State would 
find itself committed to heavy expenditure upon the staff- 
ing, civil and medical, of the hospitals, and would find 
simultaneously the ordinary income of the hospital rapidly 
decline. Under present circumstances therefore it may 
be assumed that nationalisation or municipalisation of the 
voluntary hospitals is a remote contingency. 

Nevertheless the voluntary hospitals must form an 
important part of a local medical service ; and this could 
be effected by empowering the Local Health Council to 
make any agreements with the hospitals which seemed 


suitable and were acceptable to both parties. In some 
districts the Health Council might itself supplement 
the voluntary provision by building or enlarging its own 
hospitals ; in other districts it might agree with the 
voluntary hospitals for the latter to undertake the treat- 
ment of a certain number of persons, or of certain types of 
diseases or special affections : and in yet others it might 
assist the hospitals to enlarge their buildings. But the 
last two suggestions involve payment to the funds of the 
hospitals, and this is the crux of the difficulty, for the 
moment public money is paid, the cry is raised that public 
control should be exercised. Now this is undoubtedly a 
sound general principle, but it may be carried too far if it 
exacts control on purely theoretical grounds where no 
reasonable need for that control exists. Whatever may 
be the technical position, the public already possesses a 
substantially greater degree of control over the hospitals 
than it does over Government Departments, for the 
former are amenable to public opinion while the latter are 
almost regardless of this. Moreover, the principle is even 
now not rigidly observed. In various parts of the country 
Local Education Authorities have made arrangements 
with voluntary hospitals to treat school children for ring- 
worm, defective eyesight, enlarged tonsils, etc., and for 
these services substantial contributions have been paid to 
the hospital fimds, but the Education Authorities have not 
stipulated for any voice in the internal administration of 
the hospitals. Another instance is afforded by the recent 
provision for the treatment of venereal diseases by the 
voluntary hospitals, where, though public money is to be 
spent, neither the Local Government Board nor Local 
Authorities have claimed any right to interfere with the 
management of the hospitals. 

These arrangements afford instances of the way in 
which voluntary hospitals could be fitted into a scheme 
for a local medical service. In some instances, however, 
Local Health Councils may wish to make substantial 
grants for enlarging or rebuilding hospitals, and in these 
cases it is suggested that the Health Council should 
have the right to satisfy itself that the grant is actually 


expended upon the purpose for which it is made. If a new 
wing is to be built, the Health Council shall have the 
right to see that the money is spent exclusively upon that 
new wing, and no part of it upon repairs or reconstruction 
of older buildings ; and if the Health Council agrees to 
pay for the annual maintenance of a hundred beds in the 
hospital, it shall be entitled to see the accounts and ascer- 
tain that the money is spent solely upon those beds ; but 
this right should give it no voice in the making of appoint- 
ments, or in medical or administrative questions except 
such as may be agreed upon. These powers would form a 
sufficient safeguard of public interests, and at the same 
time would probably be regarded as reasonable by the 
hospital managers. If the proposal that the voluntary 
hospitals should nominate certain members of the Local 
Health Council be adopted, agreements between the two 
bodies would be facilitated. 


The main object of this book has been to demonstrate 
the need for complete reorganisation of the Public Health 
services. There is in this country an immense amount of 
entirely avoidable sickness, and we fail very gravely to 
make the best use of modern medical and scientific know- 
ledge to prevent it. We spend vast sums on mere pallia- 
tives, and we fail to handle vigorously the great environ- 
mental causes of disease which entail further cost by 
helping to fill our gaols, asylums, and workhouses. As a 
first and immediate step it is urged that we should create a 
Ministry of Health which should itself examine the whole 
position, and report upon what further changes are desir- 
able in the way of coordinating central administration, 
giving local authorities effective power to deal with the 
causes of disease, and making provision for the care 
and treatment of those who cannot obtain these advan- 
tages under the present confused and imperfect system. 
We must necessarily proceed by steps, but each step 
should bring nearer the achievement of a complete 


and coordinated scheme for the protection of the public 

Humanity cannot escape suffering, for that is insepar- 
able from life ; but organised society can abolish much of 
the misery which results from disease. No nation has 
yet realised the immense possibilities which exist in this 
direction, and in the past the efforts to improve Public 
Health have been haphazard and costly. But the era 
which will follow the war will see new methods adopted, 
new ideals pursued, and added value attached to human 
life. Already great changes have been effected in social 
customs, which long years of peace might have failed 
to achieve. Russia has swept away much of her drink 
traffic ; we have prolonged our hours of daylight to the 
advantage of all classes, and have made individual interests 
and rights of property subservient to the national welfare 
in a degree unprecedented. Stern lessons too have brought 
home to every one the ultimate dependence of all upon 
the produce of the land. The grave problems which the 
early years of peace must bring more and more demand 
and receive attention. We hear of vast schemes for the 
reorganisation of Imperial Government, conferences on 
trade, proposals for international co-operation, plans for 
increasing the return from the land, reform in education, 
and greater application of science to industry. But no 
insistent voice has yet made itself heard on behalf of the 
nation's health. Yet this may be the most useful task 
of all, for though material needs must be met, prosperity 
brings little happiness to those worn by disease or 
physically imperfect. Some of the steps proposed on 
economic grounds will themselves do much to promote 
national health. The benefits of settlement on the land, 
of afforestation, and of agricultural development will not 
be represented fully by increase of acres under cultivation 
or enlarged returns of wheat ; but we have no means of 
expressing in figures the further gain in human growth 
and vigour which these movements will bring. The secret 
of health is to live the life for which we are constituted ; 
but for centuries man has ignored this truth, and the loss 
of his health is the penalty demanded from him for having 


in his great cities permitted social development to outstrip 
natural evolution. To-day his knowledge is sufficient to 
enable him to work with Nature instead of against her ; 
to undo many of the evils he has unwittingly created ; 
and to save the lives of his offspring now sacrificed to the 
blind driving forces of industry. To apply this knowledge 
widespread, is one of the first tasks of Peace. 


Abortifacients, sale of, 280 
Abortion, criminal induction of, 287 
Acland, Mrs. Francis, quoted, 164, 303 
Adulteration of food, 7, 265 
Afforestation, value of, in Public Health, 

Agriculture, Board of, Public Health 

duties of, 290 
Alcoholism and disease, 141, 281 
in Liverpool, deaths from, 307 
Allbutt, Sir Clifford, on medical benefit, 

on Public Health administration, 309 
on small value of drugs, 190 
Atmosphere, effects of smoke and dust 

in, 87 
Atmospheric Pollution, Committee for 

Investigation of, 90 
Atrophy, debility, and marasmus, 

deaths from, 97 et aeq. 

Baths, insufficiency of, in Bermondsev, 
therapeutic value of, recognised in 
Greece, 3 
Bathurst, Captain, M.P., on Insurance 

Act, 133 
Beevor, Sir Hugh, M.D., on infectivity 

of tuberculosis, 51 
Birth, premature, deaths from, 98 
Birth-rate, decline of, 18 
Board, Local Government, Public 
Health duties of, 288 
of Agriculture, Public Health duties 

of, 290 
of Guardians, establishment of, 294 

Public Health duties of, 292 
of Trade, Public Health duties of, 
Bradford, earnings of panel doctors in, 
infant mortality in, 107 
medical service in, intended, 227 
Breast-feeding, 74 
Bronchitis, death-rates from, 140 
Browning, Mrs. E. B., quoted, 22 

Brownlee, Dr., on typhus, 37 

Building, cost of, 163 

Burns, Rt. Hon. John, on Public Health. 

Butter, adulteration of, 269, 273 

Cancer, mortality from, 141 

Capacity to work and sickness benefit, 

Central Mid wives Board, 291 
Chester -le-Street Rural District, condi- 
tions in, 91 
Child-bed, mortality in, 195 et seq. 
Children Act, 1908, and medical treat- 
ment, 226 
below school age, mortality in, 114 
in special schools, 129 
Committee, Medical Research, under 
Insurance Act, 257 
on Atmospheric Pollution, 90 
on Lead in Painting of Buildings, 

on Lighting in Factories, 315 
on Physical Deterioration, 308, 317 
on Registration of Death, 316 
Congenital malformations, deaths from, 

97 et seq. 
Coroner in relation to Public Health, 

292, 296 
Cream, adulteration of, 268 
Croom, Sir Halliday, M.D., on unskilled 
midwifery, 201 

Death-rate, decline of, in England and 
Wales, 35 
influence of surgery upon, 207 

Developmental conditions, infant mor- 
tality from, 97 

Diagnosis in panel practice, 180, 184 
of infectious diseases, errors in, 184 

Diarrhoea and enteritis, influence of 
dust in causing, 95 

Dick, Dr. Lawson, on rickets in London 
children, 118 

Diphtheria, decline in mortality from, 




Diphtheria, prevalence of, 47, 48 

Diseases, principal, deaths from, in 
England and Wales, 136 

Disinfection of rooms, 54 

Dispensing, cost of, 231 

Domiciliary treatment, 236 

Drugs, exaggerated belief in value of, 
169, 189 
supply of, under Insurance Act, 231 

Drummond, Dr. Maxwell, quoted, 203 

Dust and epidemic diarrhoea, 95 
effect of inhaling, on lungs, 92 
collection of, and vested interests, 26 
siding at East Dulwich, 304 

Education, Board of, Public Health 
duties of, 289 

Employment of children out of school 
hours, 126 

Enteric fever, decline of, 40 

Esmonde, Dr., on sanatorium treat- 
ment, 243 

Fabian Society, report of, on hospital 

accommodation, 176 
Factories, segregation of, 157 
Fever hospitals, utilisation of, 48 
Fildes, Dr., on syphilis in London 

infants, 81 
Fletcher, Dr., on conditions in Chester- 

le-Street Rural District, 91 
' Floating sixpence,' the, 232 
Food, adulteration of, 7, 265 

conditions under which prepared, 275 
unsound, sale of, 271 
Foods, patent and proprietary, 276 
Forbes, Dr., on infant mortality in 

Brighton, 84 
France, medical men in legislature, 

state of Public Health in, 215 
Fumigation of rooms, small value of, 54 

Galsworthy, Mr., quoted, 20 

Geddes, Dr. George, and puerperal 

fever, 201 
General Board of Health, 1848, 298 
Medical Council, duties of, 290 
Register Office, duties of, 288 
George, Rt. Hon. D. Lloyd, on in- 
sanitary conditions, 257 
on sanatorium treatment, 241 
German origin of National Insurance 

Act, 212 
Germany, medical benefit in, 217 
sanatorium statistics in, 243 
state of Public Health in, 214 
Gibson, Dr. Thomas, on smallpox and 

typhus, 39 
Glasgow Insurance Committee and 
validity of Regulations, 219 

Glasier, Mrs. Bruce, on rural housing, 

Greenwood, Dr., quoted, 76 
Guardians, Board of, Public Health 

duties of, 292 

' Half-timers,' illegal employment of, 

Hammurabi's Code of Laws, 2 

Hewlett, Prof., on tuberculosis, 43 

Hillier, Dr., on sanatorium treatment, 

Home Office, Public Health duties of, 

Hospital accommodation, 176 

Hospitals, deaths in, 173 
fever, admissions to, 48 
position of, in public medical service, 

Houses, early efforts to prevent over- 
crowding of, 5 

Housing, defective, 6, 158 

India, disease in, 15 
Infant mortality and industrial employ- 
ment of women, 75 

and maternal ignorance, 77 

and occupation of father, 63 

and pre-natal conditions, 81 

and social conditions, 83 

causes of, 70 et seq. 

decline of, 105 

highest rates of, 66 

in Bradford, 107 

in Brighton, 84 

in France, 67 

in Germany, 214 

in Ireland, 67 

in London Boroughs, 83, 84 

in Paris, 89 

in Scotland, 96 

in United Kingdom, 65 

in Villiers le Due, 63 

lowest rates of, 64 

pathological causes of, 93 
Infant welfare, authorities concerned 

with, 302 
Inspectors and visitors, list of, 303 
Institutional treatment, growth of, 172 
Insurance Act v. National Insurance 
Committee, reports by, 258 
duties of, 292 
Ireland, infant mortality in, 67 

uncertified deaths in, 207 

vital statistics of, 308 

Keith, Prof., on teeth in Neolithic 

skeletons, 149 
Kerr-Love, Dr., on weights of infants 

at birth, 86 



Laboratories for special diagnosis, 186 
Leeds, soot-fall in, 88 
Leprosy, precautions against, among 
Israelites, 2 
precautions against, in Middle Ages, 
Lesser, Mr. E., on Public Health in 

Germany, 215 
Letchworth, town planning in, 157 
' Lightning ' diagnosis, 180 
Local Government Board, creation of, 
Public Health duties of, 288 
Health Committees in Insurance 

Bill, 222 
medical service proposed, 340 
sanitary authority, duties of, 291 
London, infant mortality in, 88 

overcrowding in, 154 
Long, Rt. Hon. Walter, on sanatorium 

treatment, 242 
Low, Dr. Bruce, on typhus, 37 
Lungs, effect of inhaling dust upon, 92 
Lynch, Mr. Arthur, on sanatorium 

treatment, 242 
Lyster, Dr., on relative unimportance 
of housing, 162 

Macaulay, Lord, on employment of 
school children, 129 

McMillan, Miss Margaret, on public 
distrust of doctors, 328 

Malaria, Sir Ronald Ross on, 14 

Malingering, apparent frequency of, 
under Insurance Act, 247 

Malnutrition in school children, 121 

Maternal ignorance as cause of infant 
mortality, 77 et seq. 
mortality in child -bed, 195 et seq. 

Maternity benefit, value of, 204 
service considered, 205 

Maxwell, Dr. Drummond, on unskilled 
midwifery, 203 

Maxwell, Sir John Stirling, on afforesta- 
tion, 152 

Measles, death-rates from, 49, 140 

Meat, unsound, sale of, 271, 274 

Medical Act, 1858, 284 
benefit, 224 

in Germany, 217 
records under Insurance Act, 259 
service at Swindon, 342 
local or national, 340 
treatment, and Public Health, 206 
meaning of, 168 

' Medicated ' wines, sale of, 281 

Medicines, patent and proprietary, sale 
of, 278 

Metchnikoff on tuberculosis, 44 

Metropolitan Asylums Board and pro- 
vision of sanatoria, 296 

Metropolitan Asylums Board, beds in 
hospitals of, 49 
duties of, 295 

erroneous diagnosis in cases sent to 
hospitals of, 185 
Midwives and maternal mortality, 200, 
attendance by, and infant mortality, 
Milk, adulteration of, 266 
Mortality in early childhood, 114 

National Insurance Act, administration 
of, 219 

and advancement of knowledge, 256 

and insanitary conditions, 249 

German origin of, 212 

maternity benefit, 204 

medical benefit, 224 
records, 259 

Research Committee, 257 

sickness benefit, 245 
National medical service considered, 340 
Newman, Sir George, on defective 
children, 129 

on defects in school children, 119 

on infant mortality, 71 

on vigour at birth, 82 
Newsholme, Dr., on infant mortality, 

on syphilis as cause of still-births, 103 
Notification of Births Act, 106 

Overcrowding, early efforts to prevent, 
evil effects of, 153, 161 
' Overlying,' cause of death in, 298 

Panama Canal, construction of, delayed 

by disease, 12 
Panel practices, size of, 178 
Paris, infant mortality in, 89 
Pathological causes of infant mortality, 

Pearson, Prof. Karl, on Scottish vital 

statistics, 309 
on tuberculosis, 43 
Phthisis, death-rates from, in England 
and Wales, 240 
death-rates from, in Metropolitan 

Boroughs, 139 
Physical Deterioration, Committee on, 

308, 317 
Plague, mediaeval efforts to stay, 3 
Pneumonia, death-rates from, 140 
Poor Law medical service, evolution of, 

Population, densities of, in London and 

vicinity, 154 
Poverty and infant mortality, 72 
Pregnancy, notification of, 303 



Premature birth, deaths from, 97 et seq. 

Pre-natal conditions and infant mor- 
tality, 81 

Privy Council, Public Health duties of, 

Public Health reports, uncoordination 
of, 306 

Puerperal fever, 200 

Records/medical, under Insurance Act, 

Recruits, defects in, 134 
Reeves, Mrs. Pember, on family budgets 

among poor, 79 
Register of sickness recommended, 308 
Registrar-General and Ministry of 

Health, 319 
Research Committee under Insurance 

Act, 257 
Rickets in young children, 118 
Robinson, Mr. R. A., on adulteration of 

food, 271 
Rolleston, Dr. J. D., baths in ancient 

Greece, 3 
Roscoe, Rev. J., on syphilis in Uganda, 

Ross, Sir Ronald, on malaria, 14 
Royal College of Physicians, resolution 

on unqualified practice, 285 
report on infectivity of tuberculosis, 

Royal Commission on Sewage Disposal, 

on Tuberculosis, 315 
on Venereal Diseases, 103, 143, 286, 

Royal Commissions and Public Health, 

' Rural ' and ' Urban ' Districts, dis- 
tinction between, 68 
Rural depopulation, 151 

Sale of Food and Drugs Act, 270 
Sanatorium benefit, 235 et seq. 

administration of, 300 
Scarlet fever, mortality from, 40 

prevalence of, 47 
Scharlieb, Dr. Mary, on syphilis and 

infant mortality, 71 
School children, defects in, 120 et seq. 
employment of, 126 
medical treatment of, 192 
nurse, 195 
Scottish vital statistics, Prof. Karl 

Pearson on, 309 
Sewage Disposal, Royal Commission on, 

Ship Captain's Medical Guide, 290 
Sickness benefit, 245 

rates in men and women, 28 
urban and rural, 132 

Simon, Sir John, on Departmental 
administration, 325 

on General Board of Health, 299 
Sleeping out, 166 
Smallpox, decline of, 39 

variations in death-rate from, 33 
Smoke, pollution of atmosphere by, 

88, 90 
Spencer, Herbert, on General Board of 

Health, 298 
Statistics uncoordination of, 305 
Stevenson, Dr., on chances of survival 
in infants, 86 

on infant mortality and father's 
occupation, 84 

on probable decline of syphilis, 144 
Still-births, 103 

' Summer camps ' proposed, 165 
Surgery, influence of, on death-rate, 207 
' Survival- value ' of national health, 10 
Swindon, medical service at, 342 
Syphilis as cause of still-births, 103 

decline of, 44, 144 

in London infants, 81 

in Uganda, 15 

mortality from, 142 

Teeth, condition of, in school children, 
defective, as cause of rickets, 118 
Trade, Board of, Public Health duties 

of, 289 
Treasury, the, Public Health duties of, 

Tuberculosis and infection, 50 
decline of, 42 et seq. 
mortality from, 137 
Typhus, decline of, 35 et seq. 

Uganda, syphilis in, 15 
Uncleanliness in school children, 124 
Unqualified practice, 283 
Unsound food, sale of, 271 

Vaccination, provision of, 295 

Venereal disease, treatment of, by un- 
qualified persons, 286 
Diseases, Royal Commission on, 103, 
143, 286, 316 

Vincent, Dr. Ralph, on zymotic en- 
teritis, 95 

Voluntary hospitals, position of, in 
public medical service, 344 

Wanklyn, Dr., on housing conditions 
in London, 78 
on overcrowding in London, 154 
Westminster Health Society, 118 
Whooping-cough, death-rates from, 49, 

Women and sickness rates, 28 

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